3-way Stopcock Research Articles

582. Impact of Central Line Bundle for Prevention of Umbilical Vein Catheter-Related Bloodstream Infections in a Neonatal Intensive Care Unit

BackgroundUmbilical vein catheters (UVC) are one of the most common types of vascular access device in the neonatal intensive care units. Central line-associated bloodstream infections were reported to be in the first place of healthcare-associated infections in preterm infants. In this study, we aimed to evaluate the effectiveness of the bundle applications in the prevention of umbilical vein catheter-associated bloodstream infections in neonates including premature infants.MethodsThis 40 months cross-sectional study included two periods, including pre-bundle period (from August 1, 2015 to March 31, 2017) and bundle period (April 1, 2017 to November 30, 2018). The umbilical vein catheter-related bloodstream infections, catheter line days, number of the patients were recorded and compared between the prebundle and bundle periods. Bundle steps were defined as education-training-assignment, evaluation of daily catheter indications, hand hygiene and aseptic technique while insertion, maximal sterile barrier precautions, closure of the catheter area with transparent semi-permeable membrane, using needless connectors in stead of 3-way stop-cocks, and single-use prefilled saline syringes for flushing.ResultsDuring the whole study period total umbilical vein catheter days were 2,228 days. During the prebundle period there was 10 and in the bundle period there was 2 umbilical vein catheter-related bloodstream infections (Table 1). While umbilical vein-associated bloodstream infection rate was 8.9 per 1,000 catheter days in the pre-bundle period, and significantly decreased to 1.79 in the bundle period (P < 0.05). After the introduction of bundle applications, it was observed that the rate of infection decreased by 68% (P < 0.05)ConclusionOur study showed that implementation of central line bundle including needless connectors and single-use prefilled syringes for umbilical vein-related bloodstream infections was effective for the prevention of catheter-related bloodstream infections in neonatal intensive care units. Disclosures All authors: No reported disclosures.

Connectors as a risk factor for blood-associated infections (3-way stopcock and needleless connector): A randomized-experimental study

Microorganisms causing catheter-related bloodstream infections colonize to intravenous catheters (IVC)-particularly to connectors mounted to catheters. The aim of this study was to examine the colonization in 3-way stopcock (TWS) connectors and needleless connectors (NCs) that integrated into central, port, and peripheral venous catheters. This random, experimental study consisted of 180 connectors that were inserted into the IVCs of patients in general surgery, reanimation intensive care, and daily chemotherapy units. Cultures of the connectors were obtained at least 48 hours after connecting to IVCs. This study showed that gram-negative, gram-positive, and other pathogens reproduced, although their colonization level was not high enough to develop an infection. When the results of colonization for patients using TWS and NC were compared, the peripheral venous catheters (using a TWS) resulted in a significantly higher increase in reproduction than in patients using NC (P ≤ .01) and no significant difference in the level of colonization in other types of connectors or catheters (P ˃ .05). The study's results indicated no significant difference between NC and TWSs in terms of reproduction. It should also be noted that connectors integrated into IVC pose a risk in the development of catheter-related bloodstream infections.

Impact of needle-free connectors compared with 3-way stopcocks on catheter-related bloodstream infection rates: A meta-analysis

Needle-free connectors (NFCs) were introduced to eliminate the use of needles in intravascular catheters, and their newest generations were designed to improve patient safety and reduce catheter-related bloodstream infection (CRBSI) risks. The aim of this meta-analysis was to compare NFCs with 3-way stopcocks (3WSCs) and their effects on CRBSI rates. A meta-analysis was conducted using a research protocol consistent with the PRISMA statement for reporting meta-analyses. The Cochrane Database of Systematic Reviews and MEDLINE were searched for relevant randomized studies published from January 2000 to September 2018. We identified and selected for the meta-analysis 8 studies comparing CRBSI rates (according to the Centers for Disease Control and Prevention's National Healthcare Safety Network definition) associated with NFCs utilizing negative-displacement, neutral-displacement, or positive-displacement devices with rates for 3WSCs. Relative risk was 0.53 with a 95% CI of 0.28 to 1.00, and the relative difference was -0.018 with a 95% CI of -0.039 to 0.004. CRBSI risk was statistically higher for 3WSCs compared to NFCs.

Use of a Glass Membrane Pumping Emulsification Device Improves Systemic and Tumor Pharmacokinetics in Rabbit VX2 Liver Tumor in Transarterial Chemoembolization.

To evaluate the phamacokinetics of epirubicin in conventional transarterial chemoembolization using a developed pumping emulsification device with a microporous glass membrane in VX2 rabbits. Epirubicin solution (10 mg/mL) was mixed with ethiodized oil (1:2 ratio) using the device or 3-way stopcock. Forty-eight rabbits with VX2 liver tumor implanted 2 weeks prior to transarterial chemoembolization were divided into 2 groups: a device group (n= 24) and a 3-way-stopcock group (n= 24). Next, 0.5 mL of emulsion was injected into the hepatic artery, followed by embolization using 100-300-μm microspheres. The serum epirubicin concentrations (immediately after, 5 minutes after, and 10 minutes after) and the tumor epirubicin concentrations (20 minutes after and 48 hours after) were measured after transarterial chemoembolization. Histopathologic evaluation was performed with a fluorescence microscope. The area under the curve and maximum concentrations of epirubicin in plasma were 0.45 ± 0.18 μg min/mL and 0.13 ± 0.06 μg/mL, respectively, in the device group and 0.71 ± 0.45 μg min/mL and 0.22 ± 0.17 μg/mL, respectively, in the 3-way-stopcock group (P= .013 and P= .021, respectively). The mean epirubicin concentrations in VX2 tumors at 48 hours in the device group and the 3-way-stopcock group were 13.7 ± 6.71 and 7.72 ± 3.26 μg/g tissue, respectively (P= .013). The tumor necrosis ratios at 48 hours were 62 ± 11% in the device group and 51 ± 13% in the 3-way-stopcock group (P= .039). Conventional transarterial chemoembolization using the pumping emulsification device significantly improved the pharmacokinetics of epirubicin compared to the current standard technique using a 3-way stopcock.

Application study on improving the methods of endotracheal cuff pressure measurement to prevent ventilator-associated pneumonia

To compare the intra cuff pressure changes during improved and the traditional method of cuff pressure measurement, then evaluate the effects of ventilator-associated pneumonia (VAP) prevention. The results highlighted practical recommendations in the process of ETT cuff pressure measurement. (1) Experimental studies were carried out on the tracheal model with two groups: traditional pressure measurement group and improved pressure measurement group. The traditional pressure measurement group was connected to a handheld pressure gauge with the indicate cuff to get the intra-cuff pressure. The improved method was to insert a 3-way stopcock between the handheld pressure gauge and the indicate cuff. The 3-way stopcock to stabilize handheld pressure gauge reading at 32 cmH2O (1 cmH2O = 0.098 kPa) before measure the intra-cuff pressure. The pressure loss caused by two pressure measurement methods and the leakage of liquid on the balloon after 10 minutes was compared. (2) Clinical researches: a historic cohort study, patients with mechanical ventilation (MV) admitted to intensive care unit (ICU) of Guangxi Medical University Cancer Hospital from June 2014 to May 2018 were enrolled. The control group (249 cases) was treated with traditional method during June 2014 to May 2016, and the observation group (314 cases) was treated with improved method during June 2016 to May 2018. Clusters of strategies and actions of VAP prevention were applied in both groups. Incidence of VAP, duration of MV, and the length of ICU stay were compared between the two groups. (1) Experimental study: the pressure leakage of the traditional pressure measurement group was (10.18±0.47) cmH2O, and that of the improved pressure measurement group was (1.33±0.42) cmH2O, with statistically significant difference between the two groups (t = 32.535, P = 0.000). All fluid on the cuffs leak after 10 minutes of traditional ways of measurement, however, no visible fluid on the cuffs leaked with improved procedures. (2) Clinical research: the incidence of VAP in the observation group was slightly lower than that in the control group, however there was no significant difference [5.10% (16/314) vs. 8.43% (21/249), P > 0.05]. The duration of MV and the length of ICU stay in the observation group were significantly shorter than those in the control group (days: 9.93±3.14 vs. 16.77±5.45, 11.63 ±2.28 vs. 19.12±5.10, both P < 0.01). The improved procedures of intra-cuff pressure measurement is a practical method to avoid the pressure leakage and fluid leakage, and the clinical course of MV patients can be significantly improved by combining the clusters of nursing strategies and actions.

Myocardial Monophasic Action Potential Recorded by Suction Electrode for Ionic Current Studies in Zebrafish.

The study of myocardial transmembrane ion currents is fundamental to understand frequent pathologies such as arrhythmias and ischemia. Conventional electrocardiography (ECG) is not able to record ion currents, while the use of intracellular microelectrodes in a beating heart has technical limitations. Myocardial monophasic action potentials (MAPs) recorded with suction electrodes allow the evaluation of ionic currents similar to those recorded by intracellular glass microelectrodes. The technique is based on the fact that suction, through a small diameter tube, on the myocardial cell, induces an opening at the membrane, connecting the intracellular media to the electrode by a saline bridge. The electrophysiology of zebrafish heart is remarkably similar to the human; however, in situ evaluation of MAPs has not been yet explored. In this study, we aimed to establish a myocardial MAP recording technique for adult zebrafish. Male adult wild-type zebrafish were anesthetized and 50% of the beating ventricle was exposed. A glass hematocrit capillary tube (1.1 mm inner diameter) was used as a suction electrode connected to a 3-way stopcock valve, which is also connected to a syringe containing a chloride-coated silver wire for signal recording. Gentle suction was exerted by a syringe filled with ringer and connected to the 3-way stopcock valve. Two needles were used for ground (tail) and indifferent (abdomen) electrodes. Without suction, the system can record conventional ECG, but applying suction MAPs are registered and show typical morphology with phase 0-4 sequence. MAP amplitude and duration values show low variability. Ischemia and/or lidocaine-induced Na+ channel blocking dramatically reduced MAP amplitude. These results strongly suggest that the suction electrode technique is a promising method to record myocardial ion currents in situ in zebrafish.

The change of endotracheal tube cuff pressure during laparoscopic surgery

BackgroundWe evaluated the endotracheal tube cuff pressure (Pcuff) changes during pneumoperitoneum for laparoscopic cholecystectomy and the correlations between body mass index (BMI), pneumoperitoneum time, and Pcuff changes.MethodsTotal 60 patients undergoing laparoscopic cholecystectomy were allocated to either a study group (BMI ≥ 25 kg/m2) or a control group (BMI < 25 kg/m2). The endotracheal intubation was performed with a high-volume low-pressure cuffed oral endotracheal tube. A manometer was connected to the pilot balloon using a 3-way stopcock and the cuff was inflated. The change in Pcuff was defined as the difference between the pressure just before intra-abdominal CO2 insufflation and the pressure before CO2 desufflation.ResultsPcuff increased to 5.3 ± 3.6 cmH2O in the study group and 5.7 ± 5.4 cmH2O in the control group. There was no significant difference between two groups. While BMI was not correlated with change in Pcuff (r = 0.022, p = 0.867), there was a significant correlation between change in Pcuff and the duration of pneumoperitoneum (r = 0.309, p = 0.016).ConclusionThe change in Pcuff was not affected by BMI and was significantly correlated with pneumoperitoneum time. We recommend regular measurement and adjustment of Pcuff during laparoscopic surgery.

Ex Vivo Evaluation of Residual Activity and Infusion Dynamics in a Commercially Available Yttrium-90 Resin Microsphere Administration System

PurposeTo evaluate the infusion dynamics and residual yttrium-90 activity during and after resin microsphere radioembolization with different injection techniques and initial activities. To assess the distribution of residual activity in the administration systems to allow optimization of the procedure and the equipment. Materials and MethodsIn a setup similar to that in standard clinical practice, radioembolization procedures were performed ex vivo. The influence of different injection techniques was assessed by comparing pulsatile and continuous injections. The influence of the absolute amount of activity to the residual activity was assessed by comparing pulsatile 0.5-GBq- with 1.0-GBq-procedures. Continuous dose rate measurements were performed. Activity distribution was determined by positron-emission tomography (PET)/CT. ResultsFifteen procedures were performed: 5 pulsatile 0.5-GBq-, 5 continuous 0.5-GBq-, and 5 pulsatile 1.0-GBq-procedures. Mean residual activity was 4.0% ± 1.7% (range 1.2%–6.6%), without statistically significant differences between injection techniques (P = .841) or between prescribed activities (P = .222). Dose-rate measurements revealed an exponential decrease of the activities in the vials with high variability. Activity fell rapidly to 32% ± 7.9% (range 23%–55%) after injection of 4 of 20 mL 5% dextrose solution. Residual activity accumulations were identified at the 3-way stopcock (100% of procedures), in the C-line (80%), at the microcatheter connector (20%), and in the A-line (6.7%), but not in the vials. ConclusionsResidual activity in a commercial administration system for resin microsphere radioembolization is variable and does not systematically depend on initial yttrium-90 activity or on injection technique. Predilection sites for residual activity were identified, which should receive special attention when performing resin transarterial radioembolization procedures, and for further administration system developments.

Alternate method of loss of resistance test using 3-way stopcock and two syringes.

Alternate method of loss of resistance test using 3-way stopcock and two syringes.

A Comparative Study on the Contamination Level of Intravenous Infusion Ports: A Comparison of 3-way Stopcock (Open-system) and Needleless Connector (Closed-system)

A Comparative Study on the Contamination Level of Intravenous Infusion Ports: A Comparison of 3-way Stopcock (Open-system) and Needleless Connector (Closed-system)

Gelatin Paste as an Alternative Cost-Effective Hemostatic Agent in Cranial Surgery: Doing More with Less

To present an alternative cost-effective hemostatic agent (HA) for cranial surgery and to describe the technique to produce it. This HA has been used in 3 reference centers over the last year during 230 procedures, including different types of pathology, such as skull base, oncology, vascular, and trauma, either for endoscopic or open approaches. This agent was made from a low-cost and worldwide-available gelatin foam which was mixed with saline solution in 2 syringes and connected by a 3-way stopcock, making a useful hemostatic paste. The cost was 16 and 28 times less than SURGIFLO and FLOSEAL, respectively. The mean time to prepare the mix was 4 minutes. It was very effective for venous and low-flow bleeding. The presented technique offers a reliable and cost-effective way of achieving hemostasis in cranial surgery, therefore allowing hospitals with limited resources to perform advanced procedures in a safer way.

Influence of contrast-enhanced ultrasound administration setups on microbubble enhancement: a focus on pediatric applications.

In pediatrics, contrast-enhanced ultrasound offers high-quality imaging with an excellent safety profile. To investigate the effects of varying intravenous administration setups on in vitro enhancement and concentration of two commercially available ultrasound contrast agents, taking into consideration potential pediatric applications. We quantified in vitro enhancement using a flow phantom (ATS Laboratories, Bridgeport, CT) and Acuson S3000 ultrasound system (Siemens Healthineers, Mountain View, CA) with a 9L4 probe in Cadence pulse sequencing mode. We determined microbubble concentration with an LSRII flow cytometer (BD Biosciences, San Jose, CA). We investigated Optison (GE Healthcare, Princeton, NJ) and Lumason (Bracco, Geneva, Switzerland) ultrasound contrast agents. The ultrasound (US) contrast agent was injected via a 1 mL syringe and flushed with 5 mL of saline through a 22-gauge diffusion catheter (BD Medical, Franklin Lakes, NJ) with the following variations: in-line injection through a 3-way stopcock with and without a neutral displacement connector (ICU Medical, San Clemente, CA), perpendicular through a 3-way stopcock with and without a connector, and without a 3-way stopcock. We also conducted injections through a 22-gauge standard angiocatheter. Injection through the connector and perpendicular injection via the 3-way stopcock resulted in significant decreases in enhancement for both ultrasound contrast agents (P<0.0001). Injection through the connector resulted in significant decrease in concentration for Optison (P<0.05). Neither addition of the 3-way stopcock (P>0.24) nor use of a pediatric diffusion catheter (P>0.28) affected the enhancement. Ultrasound contrast agent enhancement depends on the administration route, although some effects appear to be specific to the ultrasound contrast agent used. To avoid loss of enhancement, neutral displacement connectors and perpendicular injection should be avoided.

Parameters for Stable Water-in-Oil Lipiodol Emulsion for Liver Trans-Arterial Chemo-Eembolization.

Water-in-oil type and stability are important properties for Lipiodol emulsions during conventional trans-arterial chemo-embolization. Our purpose is to evaluate the influence of 3 technical parameters on those properties. The Lipiodol emulsions have been formulated by repetitive back-and-forth pumping of two 10-ml syringes through a 3-way stopcock. Three parameters were compared: Lipiodol/doxorubicin ratio (2/1 vs. 3/1), doxorubicin concentration (10 vs. 20mg/ml) and speed of incorporation of doxorubicin in Lipiodol (bolus vs. incremental vs. continuous). The percentage of water-in-oil emulsion obtained and the duration until complete coalescence (stability) for water-in-oil emulsions were, respectively, evaluated with the drop-test and static light scattering technique (Turbiscan). Among the 48 emulsions formulated, 32 emulsions (67%) were water-in-oil. The percentage of water-in-oil emulsions obtained was significantly higher for incremental (94%) and for continuous (100%) injections compared to bolus injection (6%) of doxorubicin. Emulsion type was neither influenced by Lipiodol/doxorubicin ratio nor by doxorubicin concentration. The mean stability of water-in-oil emulsions was 215±257min. The emulsions stability was significantly longer when formulated using continuous compared to incremental injection (326±309 vs. 96±101min, p=0.018) and using 3/1 compared to 2/1 ratio of Lipiodol/doxorubicin (372±276 vs. 47±43min, p=<0.0001). Stability was not influenced by the doxorubicin concentration. The continuous and incremental injections of doxorubicin in the Lipiodol result in highly predictable water-in-oil emulsion type. It also demonstrates a significant increase in stability compared to bolus injection. Higher ratio of Lipiodol/doxorubicin is a critical parameter for emulsion stability too.

Techniques to Form a Suitable Lipiodol-Epirubicin Emulsion by Using 3-Way Stopcock Methods in Transarterial Chemoembolization for Liver Tumor

PurposeTo compare physicochemical properties of emulsions of ethiodized oil (Lipiodol; Guerbet, Villepinte, France) and epirubicin prepared using different techniques for conventional transarterial chemoembolization. Materials and MethodsLipiodol was mixed with epirubicin solution (8.33 mg/mL) by using a 3-way stopcock. The following technical parameters were compared: ratio of epirubicin solution to Lipiodol (1:2 vs 1:1), number of pumping exchanges through the stopcock (20 exchanges vs 10 exchanges), pumping speed (1 s/push vs 2 s/push), and first push syringe (epirubicin solution vs Lipiodol). ResultsThe mean percentage of water-in-oil was 70.45 ± 1.51 in the 1:2 epirubicin-Lipiodol ratio and 16.03 ± 2.95 in the 1:1 ratio (P < .001). The first push syringe did not influence emulsion type. Median droplet sizes were significantly larger in the slower pumping speed (52.0 μm in 2 s vs 33.7 μm in 1 s; P < .001), whereas there was no significant difference in number of pumping exchanges. Droplet sizes enlarged during 30 minutes after pumping. Viscosity was lower in the 1:1 ratio and the slower pumping speed. Viscosity decreased during 30 minutes after pumping. ConclusionsThe ratio of epirubicin to Lipiodol is a significant factor to form water-in-oil emulsions with higher viscosity. The percentage of water-in-oil is limited to 70% using current pumping techniques. The pumping speed strongly influences droplet size and viscosity.

MP82-06 DETRUSOR UNDERACTIVITY IN AN OBESE-PRONE RAT MODEL

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Basic Research & Pathophysiology II1 Apr 2017MP82-06 DETRUSOR UNDERACTIVITY IN AN OBESE-PRONE RAT MODEL Eric Gonzalez and Warren Grill Eric GonzalezEric Gonzalez More articles by this author and Warren GrillWarren Grill More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2553AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Detrusor underactivity (DUA) is an understudied health concern that affects up to 45% of men and women in secondary care. The clinical management of DUA is inadequate and fails to improve the quality of life of these patients. The limited availability of animal models that exhibit the integrated pathophysiology of DUA impedes the development of new therapeutic approaches. The current studies characterized the bladder function of an obesity model of DUA to increase our understanding of the initiation and progression of urinary retention. METHODS Animals: Eight-week old female obese-prone (OP) and obese-resistant (OR) rats purchased from Charles River (Boston, MA) were housed two per cage and maintained in standard laboratory conditions with food and water available ad libitum. Experimental procedures were approved by the Duke University IACUC and experimentation was conducted in accordance with the NIH Guide for the Care and Use of Laboratory Animals (8th ed.). High-fat feeding and glucose measurements: OP and OR rats were fed a 45% fat diet (D12451, Research Diets, Inc.) from 9-21 weeks and a 60% fat diet (D12492, Research Diets, Inc.) from 21-24 weeks. Whole blood was collected from the tail vein for glucose analysis at 8 and 24 weeks. Surgical preparation and instrumentation: At 24 weeks, OP and OR rats were anesthetized with urethane (1.2 g/kg s.c. and supplemented as needed). The bladder was exposed through a midline abdominal incision and a flared PE-60 catheter was inserted into the bladder dome. The catheter was secured and connected via a 3-way stopcock to a pressure transducer and infusion pump. A paddle with platinum iridium contacts was placed between the pubic symphysis and the EUS to record EMG signals. Pressure and EMG signals were amplified, filtered, and sampled on a PowerLab acquisition unit with LabChart 7 Pro. RESULTS OP rats weighed significantly more than OR rats (450 ± 11.1 vs. 270 ± 6.7 g, respectively; p ≤ 0.001); however, blood glucose was not altered between OP (169.1 ± 7.11 mg/dl) or OR (176.5 ± 6.09 mg/dl; p ≥ 0.05) rats. Compared to OR rats, OP rats have significantly increased volume threshold (0.7574 ± 0.07 vs. 0.529 ± 0.04 ml; p ≤ 0.05), decreased maximum micturition pressure (16.62 ± 1.2 vs. 23.94 ± 1.1 cmH2O; p ≤ 0.001), and decreased voiding efficiency (8.743 ± 2.58 vs. 42.19 ± 6.5 %; p ≤ 0.001). CONCLUSIONS OP rats exhibit DUA and decreased voiding efficiency. This animal model may be used to understand the pathophysiology underlying DUA and enable the development of novel therapeutic approaches to recover efficient voiding. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1099 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Eric Gonzalez More articles by this author Warren Grill More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Potential impact of oxygenators with venous air trap on air embolism in veno-arterial Extracorporeal Life Support.

Air embolism is a potentially fatal but underrecognized complication in Extracorporeal Life Support (ECLS). Oxygenators containing venous air traps have been developed to minimize the risk of air embolism in daily care. We reproduced air embolism as occurring via a central venous catheter in an experimental setting to test the potential of oxygenators with and without venous bubble trap (VBT) to withhold air. An in vitro ECLS circuit was created and a central venous catheter with a 3-way stopcock and a perforated male luer cap was inserted into the inflow line. Three different oxygenators with and without VBT and their capability to withhold air were examined. After 60 seconds of stable ECLS flow, the stopcock was opened towards the atmosphere for 3 minutes. Afterwards, air accumulation within the oxygenator was determined. Comparison of the total air entrapment showed a significant superiority of the oxygenators with VBT (p < 0.001). All oxygenators were able to partly withhold macro air boli, however, the capacity of oxygenators with VBT was higher. Passing through the oxygenator resulted in a reduction of microbubbles in all cases. Macro air emboli can be substantially reduced by usage of oxygenators that contain a VBT, whereas the capability to withhold microbubbles to a vast extent seems to depend on the intrinsic oxygenator's membrane.

Remifentanil and propofol undergo separation and layering when mixed in the same syringe for total intravenous anesthesia.

Propofol and remifentanil can be combined to deliver total intravenous anesthesia (TIVA). Propofol and remifentanil are sometimes mixed in the same syringe. Since remifentanil is a solution and propofol is an emulsion, we hypothesized that they would separate over time when mixed in the same syringe. Nine 60-ml polypropylene syringes were prepared as follows: Group A: 1.25 ml of remifentanil solution (1 mg·ml(-1) ) was added to 48.75 ml of propofol (10 mg·ml(-1) ) in three syringes. Group B: 2.5 ml of remifentanil (1 mg·ml(-1) ) was added to 47.5 ml of propofol (10 mg·ml(-1) ) in three syringes. Group C: 5 ml of remifentanil (1 mg·ml(-1) ) was added to 45 ml of propofol (10 mg·ml(-1) ) in three syringes. The remifentanil lyophilized powder was reconstituted with sterile water and added to the propofol by injection through the port on the bottom of the syringe. The syringe was then inverted five times in succession to mix the drugs. The syringes were mounted in an upright vertical position (plunger on top, port on bottom) with wire on a pegboard. Samples of the mixture were taken from the bottom port (via a 3-way stopcock) and from the top of the syringe (via a stopcock on an 18-gauge needle placed 5 mm through the plunger) at the following time intervals (min) from baseline: T0, T10, T30, T60, T120, T180, T240, T300. Remifentanil and propofol were quantified using specific and validated HPLC/MS/MS assays with automated online sample preparation. Concentrations of remifentanil were significantly greater at the top than the bottom of the syringes in groups A and B. Concentrations of propofol were significantly greater at the bottom than the top of the syringes in all groups. Our data indicate that remifentanil solution and propofol emulsion are immiscible: remifentanil separates from propofol and rises to the top. Thus, concentrations of remifentanil and propofol delivered to patients from the same syringe during TIVA are not those expected and cannot be reliable. Remifentanil and propofol should be administered in separate syringes when used in combination for TIVA.

Impact of a modified Broviac maintenance care bundle on bloodstream infections in paediatric cancer patients.

Background: During intensive chemotherapy, bloodstream infection (BSI) represents an important complication in paediatric cancer patients. Most patients carry a long-term central venous access device (CVAD). Improved maintenance care of these vascular catheters may decrease the risk of BSI.Methods: Intervention study (adapted CVAD prevention protocol) with two observation periods (P1: 09-2009 until 05-2011; P2: 09-2011 until 05-2013); prospective surveillance of all laboratory confirmed BSIs. In P2, ready to use sterile NaCl 0.9% syringes were used for CVAD flushing and octenidine/isopropanol for the disinfection of catheter hubs and 3-way stopcocks. Results: During P1, 84 patients were included versus 81 patients during P2. There were no significant differences between the two patient populations in terms of median age, gender, underlying malignancy or disease status (first illness or relapse). Nearly all CVADs were Broviac catheters. The median duration from implantation to removal of the CVAD was 192 days (Inter-quartile-range (IQR); 110–288 days) in P1 and 191 days (IQR; 103–270 days) in P2. 28 BSI were diagnosed in 22 patients in P1 (26% of all patients experienced at least one BSI) and 15 BSI in 12 patients in P2 (15% of all patients). The corresponding results for incidence density (ID) were 0.44 (CI95 0.29–0.62) for P1 vs. 0.34 (0.19–0.53) BSI per 100 inpatient days for P2 and for incidence rate (IR) 7.76 (5.16–10.86) in P1 vs. 4.75 (2.66–7.43) BSI per 1,000 inpatient CVAD utilization days. In P1, 9 BSI were caused by CoNS vs. only 2 in P2 (IR 2.49; CI95 0.17–4.17 vs. 0.63; CI95 0.08–1.72). In P1 two BSI (7%) lead to early removal of the device. During P2 one CVAD was prematurely removed due to a Broviac-related BSI (6.7%).Conclusion: The preventive protocol investigated in this study led to a reduction of BSI in paediatric cancer patients. This result was clinically relevant but – due to insufficient power in a single centre observation – the difference did not reach statistical significance. The most pronounced trend in BSI reduction was observed for CoNS infections. Thus, improving maintenance care of the CVAD may result in lower CVAD-linked infection rates. The higher acquisition cost of the ready to use NaCl 0.9% flushing syringes and octenidine/propanol hub disinfection were probably balanced by cost savings in the intervention period.

Creation of small gelatin particles by pumping method for transarterial chemoembolization of hepatocellular carcinoma: analysis of particle size and reproducibility.

Spherical porous gelatin particles (Gelpart(®), Nippon Kayaku, Tokyo) were crushed by a pumping method to create small gelatin particles for transarterial chemoembolization of hepatocellular carcinoma. The aim of this study was to analyze crushed particle size. To minimize the size of crushed particles, we used the pumping method using two 2.5-mL syringes connected by a 3-way stopcock. Sixteen samples created by 3 operators were examined. The crushed particles were stained with hematoxylin-eosin, images magnified by a microscope were captured using a digital camera, and the maximum length of each particle was measured. The differences in particle size within the same operator and among the 3 operators were examined by an ANOVA test. The particle sizes created by each operator were 139.0 ± 58.8, 201.1 ± 90.9, and 158.4 ± 72.0 µm, respectively. There was a statistically significant difference in particle size among the 3 operators (p < 0.01). With one operator, there was no statistically significant difference in the particle size among the 4 samples (p = 0.93). With 2 operators, there were statistically significant differences among 5, or 7 samples, respectively (p < 0.01). Small gelatin particles can be created with Gelpart(®) by the pumping method, but mean particle size was different among samples and not reproducible.

Effects of Needle and Catheter Size on Commercially Available Ultrasound Contrast Agents

To investigate effects of needle and catheter size on in vitro ultrasound contrast agent (UCA) enhancement and concentrations using 4 commercially available UCAs. Definity (Lantheus Medical Imaging, North Billerica, MA), Optison (GE Healthcare, Princeton, NJ), SonoVue (Bracco SA, Geneva, Switzerland), and Sonazoid (GE Healthcare, Oslo, Norway) were investigated. The UCA was injected via a 1-mL syringe (BD, Franklin Lakes, NJ) into a 3-way stopcock (Smith Medical, Dublin, OH) and flushed with 10 mL of saline through an 18-cm infusion extension tube connected to either a 16-, 18-, 20-, 22-, or 24-gauge catheter (BD) or an 18-, 20-, 21-, or 25-gauge needle (BD). In vitro enhancement was determined in a flow phantom (ATS Laboratories, Bridgeport, CT), and microbubble concentrations were determined using an LSRII flow cytometer (BD Biosciences, San Jose, CA). Significant decreases in enhancement and microbubble concentrations were observed for all 4 UCAs (P < .001) when administration was performed through a 25-gauge needle. No statistically significant differences in enhancement or concentrations were observed between all catheter sizes and 18- to 21-gauge needles for SonoVue and Sonazoid. Definity and Optison administration through a 24-gauge catheter resulted in a significant loss of enhancement (P < .02), although these differences were not significant on flow cytometry. Administration of commercial UCAs in a clinical scenario is possible with catheters or needles smaller than 20 gauge, although the minimal allowable size appears to be UCA specific.