Accidental Catheter Removal Research Articles

Accidental epidural catheter removal rates and strength required for disconnection: a retrospective cohort and laboratory study

BackgroundEpidural catheters are associated with certain risks such as accidental epidural catheter removal, including dislodgement and disconnection. Globally, neuraxial connector designs were revised in 2016 to provide new standardization aimed at decreasing the frequency of misconnections during the administration of medications. However, no studies have investigated accidental epidural catheter removal after the revised standardization. This study aimed to examine differences in dislodgement and disconnection rates associated with different catheter connector types, and to investigate the linear tensile strength required to induce disconnection.MethodsThis retrospective cohort study included adult patients who underwent elective surgery and received patient-controlled epidural analgesia. Patients were divided into groups according to the type of catheter connection used: old standard, new standard, and new standard with taping groups. Furthermore, we prepared 60 sets of epidural catheters and connectors comprising 20 sets for each of the old, new, and taping groups, and used a digital tension meter to measure the maximum tensile strength required to induce disconnection.ResultsThis clinical study involved 360, 182, and 378 patients in the old, new, and taping groups, respectively. Dislodgement rates did not differ statistically among the three groups, while there was a significant difference in disconnection rates. Propensity score matching analysis for disconnection rates showed no difference between the old and new groups (2.8% vs. 4.5%, p = 0.574), while the new group had higher rates than the taping group (6.5% vs. 0%, p = 0.002). This laboratory study identified that a tensile strength of 12.41 N, 12.06 N, and 19.65 N was required for disconnection in the old, new, and taping groups, respectively, and revealed no significant difference between the new and old groups (p = 0.823), but indicated a significant difference between the new and taping groups (p < 0.001).ConclusionsThis clinical study suggested that dislodgement rates did not change among the three groups. Both clinical and laboratory studies revealed that disconnection rates did not change between the old and new connectors. Moreover, as a strategy to prevent accidents, taping the connecting points of the catheter connectors led to an increase in the tensile strength required for disconnection.

Development and implementation of a novel decision support tool on physical restraint use in critically ill adult patients.

To investigate whether a novel decision support tool would effectively minimize physical restraint use in critically ill adult patients. A nonequivalent quasi-experimental design combined with a descriptive qualitative approach was used. A Restraint Decision Tree was developed based on a qualitative study that explored the barriers to employ the Restraint Decision Wheel. During the quasi-experimental study, patients admitted to the unit between October 2017 and March 2018 were enrolled as the control group receiving the Restraint Decision Wheel (n = 528), whereas patients between April 2018 and September 2018 were enrolled as the intervention group receiving the Restraint Decision Tree (n = 564). The physical restraint rate, accidental catheter removal rate and nurses' satisfaction were compared. The Restraint Decision Tree significantly decreased physical restraint use. No significant difference in the rate of accidental catheter removal was found. Nurses reported increased satisfaction with the restraint decision-making. The Restraint Decision Tree could minimize physical restraint use. Physicians' involvement in the restraint decision-making and nurses' competence in delirium assessment may be essential for successful implementation of the Restraint Decision Tree.

Povidone-iodine sclerotherapy of primary symptomatic lymphocele after kidney transplantation.

To report the efficacy and safety of povidone-iodine sclerotherapy of primary symptomatic lymphocele after kidney transplantation in a large contemporary cohort study. A single-institutional study was conducted including consecutive patients who underwent povidone-iodine sclerotherapy for primary symptomatic lymphocele after kidney transplantation between January 2013 and March 2020. Sclerotherapy was used as the first-line treatment of symptomatic lymphocele. Recurrent lymphoceles were managed with open or laparoscopic fenestration. The primary outcome was the efficacy of sclerotherapy which was defined as the absence of second sclerotherapy or salvage surgery. A total of 965 renal transplantations were included. Sclerotherapy for primary symptomatic lymphocele was performed in 60 cases (6.2%). The median (IQR) number of instillation, the volume of povidone-iodine per instillation and drainage time were 3 (3-3), 60 (38-80) mL and 6days (5-8), respectively. Sclerotherapy related complications were reported in eight cases (13.3%) and included five cases of accidental catheter removal, two cases of lumbosciatica, and one case of intraperitoneal diffusion of povidone-iodine. After a median (IQR) follow-up of 33 (14-60) months, treatment success was achieved in 33 cases (55%). Multivariate analysis failed to identify predictors of sclerotherapy failure. Salvage therapies included 7s sclerotherapy and 20 surgical fenestrations with an overall success rate of 88.8% (24/27). Sclerotherapy was an easy and safe procedure to treat primary symptomatic lymphocele in renal transplant recipients. Despite moderate efficacy, recurrences were easily controlled with salvage therapies. Further studies are necessary to identify predictive factors of sclerotherapy failure to directly refer patients to surgical treatment.

Postoperative Thoracic Epidural Analgesia: Adverse Events from a Single-Center Series of 3126 Patients.

PurposeThoracic epidural analgesia (TEA) has been shown to reduce postsurgical morbidity and mortality; nevertheless, major and minor complications can occur. We report our 10-year experience with TEA and incidence of complications.Patients and MethodsPatients received continuous infusion TEA (0.2% ropivacaine and 2 µg ml−1 fentanyl) to control postoperative pain. Every 8 hours, the acute pain service recorded the analgesia regimen and occurrence of side effects. The initial infusion rate was tapered daily in response to improvement in pain symptoms or occurrence of side effects.ResultsA total of 3126 patients received TEA. The median age was 65 years (range, 18–94) and the duration of catheter placement was 3.5 days (range, 2–8). Three major complications were identified (1:1042): two subarachnoid blocks and one epidural abscess which led to permanent sequela (1:3126). Minor complications were hypotension (4.8%), pruritus (4.4%), accidental catheter removal (3.7%), insertion site inflammation (2.5%), motor weakness (2.0%), postoperative nausea and vomiting (1.8%), catheter disconnection (1.9%), catheter occlusion (0.3%), post-dural puncture headache (0.5%), and catheter fragment retention (0.06%), which were the reasons for a 7.4% rate of early discontinuation of epidural analgesia. No occurrence of epidural hematoma, local anesthetic systemic toxicity, and cardiovascular/respiratory depression was recorded.ConclusionPostoperative TEA is an advanced technique that poses certain difficulties that can subvert its great potential. While serious complications were rare, minor complications occurred more often and affected the postoperative course negatively. A risk/benefit evaluation of each patient should be done before employing the technique.

ANALGESIC EFFECTIVENESS OF CONTINUOUS INTERSCALENE CATHETER USE FOR AMBULATORY SHOULDER SURGERY IN PEDIATRIC AND ADOLESCENT PATIENTS

BACKGROUND Continuous interscalene catheters are utilized for inpatient and outpatient postoperative pain control after shoulder surgery. Although prior studies have primarily been limited to adult populations, benefits of peripheral nerve catheters in ambulatory surgical centers have been shown to reduce post operative pain scores, opioid requirements, and post operative nausea. However, their use in a solely pediatric ambulatory setting has not been investigated. The purpose of this study was to retrospectively review the adverse events, analgesic effectiveness, and opioid use after continuous interscalene catheters for ambulatory shoulder surgery in pediatric and adolescent patients. METHODS A retrospective review was performed of 15 pediatric and adolescent patients (4 female, 11 male), mean age 16 years (range, 12-18 years), and mean weight 78.3 kg (range 53-130 kg), who underwent ultrasound-guided interscalene catheter placement for outpatient shoulder surgery from April 2017 through May 2018. All but one surgery were performed at a dedicated pediatric ambulatory surgery center. Catheters were initially dosed with 0.5% ropivacaine (n = 13) or 0.2% ropivacaine (n = 2) at volumes of 0.1-0.2ml/kg (total, 6-20 ml). By the conclusion of surgery, all catheters were continuously infusing 0.2% ropivacaine at 3-6ml/hr with the majority (n = 10) at 4ml/hr via elastomeric pumps. Time for catheter placement, intraoperative and postoperative intravenous opioids, post-anesthesia recovery unit (PACU) length of stay (LOS), PACU maximum pain scores and rescue medications for post-operative nausea and vomiting (PONV) were recorded. After discharge, all patients received multimodal analgesia (ibuprofen, acetaminophen, and rescue oxycodone). Patients were assessed on postoperative days (POD) 1-3 for numerical rating pain scores (0-10) at rest and with movement, supplemental oxycodone use in the past 24 hours, satisfaction, and adverse effects of treatment. RESULTS Catheter placement was 100% successful; no procedure had to be aborted during placement because of inability to place catheter. The average time for catheter placement was 11.8 minutes (range, 3-19 minutes). There were 3 adverse events, including one accidental catheter removal in PACU, one dressing failure requiring removal of catheter on POD 2, and one case of Horner’s Syndrome. There were no signs of infection, local anesthetic toxicity, or shortness of breath described in any patients. Short acting opioids (Alfentanil and Fentanyl) were used intraoperatively in all but 2 patients, with average dose of 8.5mcg/kg Alfentanil and 0.7mcg/kg Fentanyl. Two patients received long-acting opioids intraoperatively. The mean PACU maximum pain score was 1.4 (range, 0-9). Only 3 patients received rescue intravenous morphine in the PACU with a mean dose of 0.035mg/kg. Mean PACU LOS was 112 minutes (range, 85 – 210 minutes). No patients required any rescue PONV medications in the PACU. Mean pain scores for POD 1- 3 at rest were 2.1, 2.3, and 2.6, respectively; scores with movement were 3.6, 3, and 4.4, respectively. Mean doses (i.e., times of administration) of oxycodone on POD 1-3 respectively were 1.5, 1.3 and 0.5 (range 0-5 doses). All but one patient was very satisfied and would have the catheter placed again. CONCLUSIONS Outpatient use of continuous interscalene catheters in pediatric and adolescent patients provides excellent intraoperative and early postoperative analgesia during and following shoulder surgery. Their routine use should be considered as they minimize perioperative opioid use with minimal adverse events, adding only small delay to surgical time.

PERIPHERAL VENIPUNCTURE: COMPREHENSION AND EVALUATION OF NURSING PRACTICES

ABSTRACT Objective: to understand the nursing practices related to peripheral venipuncture and to analyze the incidence of complications in patients with venous catheters. Method: mixed design, involving: case study, sectional study, cohort study and focus group. The sample consisted of nurses and patients from a medical clinic in Portugal. Thematic analysis and descriptive statistics were performed. Results: stressors capable of influencing nursing practices were identified, including: the decisions of the medical team, the age and characteristics of the venous network of the patient, the availability of other catheters in the institution, the low level of knowledge of nurses regarding the care of patients in the insertion, maintenance and removal of the peripherally inserted central venous catheter. The following complications and their respective incidences were documented in patients with peripheral venous catheters: phlebitis (22.2%), obstruction (27.7%), fluid exiting through insertion site (36.1%), infiltration (38.8%) and accidental catheter removal (47.2%). Catheter obstruction with an incidence of 22.2% was only observed in those who used the peripherally inserted central venous catheter. The following benefits were observed with the use of the peripherally inserted central venous catheter: safe administration of drugs; pain reduction, number of venous punctures and complications. Conclusions: the peripherally inserted central venous catheter is presented as a valid and viable alternative that can improve the quality of nursing care and the safety and well-being of patients.

Heparinized saline versus normal saline for maintaining peripheral venous catheter patency in China: An open-label, randomized controlled study.

ObjectiveTo evaluate the effects of heparin saline versus normal saline as locking solution for maintaining patency in peripheral venous catheters in Chinese patients.MethodsThis open-label, randomized controlled study was conducted in two hepatobiliary surgery wards, where patients received identical treatments, at a tertiary referral hospital. Patients were randomly divided into a normal saline group (NS, 3 ml) or a heparin saline group (HS, 50 IU/ml, 3 ml) for catheter sealing.ResultsThe study enrolled 286 patients and 609 peripheral venous catheters were included in the analysis. The patients in the two groups had no local infections or catheter-related bloodstream infections. There were no significant differences between the two groups in terms of the rate of catheter obstruction, duration time, or the rates of phlebitis, infiltration, and accidental catheter removal.ConclusionsNo significant differences in the peripheral venous catheter sealing effects were observed between normal saline and heparin saline usage in Chinese patients.

Devices and dressings to secure peripheral venous catheters: A Cochrane systematic review and meta-analysis

BackgroundPeripheral venous catheterisation is the most frequent invasive procedure performed in hospitalised patients; yet over 30% of peripheral venous catheters fail before treatment ends. ObjectivesTo assess the effects of peripheral venous catheter dressings and securement devices on the incidence of peripheral venous catheter failure. Data sourcesWe searched the Cochrane Wounds Group Register, The Cochrane Central Register of Controlled Trials, MEDLINE; EMBASE and CINAHL for any randomised controlled trials comparing different dressings or securement devices used to stabilise peripheral venous catheters. The reference lists of included studies were also searched for any previously unidentified studies. ResultsWe included six randomised controlled trials (1539 participants) that compared various dressings and securement devices (transparent dressings versus gauze; bordered transparent dressings versus a securement device; bordered transparent dressings versus tape; and transparent dressing versus sticking plaster). Trial sizes ranged from 50 to 703 participants. The quality of evidence ranged from low to very low. Catheter dislodgements or accidental removals were lower with transparent dressings compared with gauze (two studies, 278 participants, risk ratio (RR) 0.40; 95% confidence interval (CI) 0.17–0.92, P=0.03%). However, the relative effects of transparent dressings and gauze on phlebitis (RR 0.89; 95% CI 0.47–1.68) and infiltration (RR 0.80; 95% CI 0.48–1.33) are unclear. A single study identified less frequent dislodgement or accidental catheter removal with bordered transparent dressings compared to a securement device (RR 0.14, 95% CI 0.03–0.63) but more phlebitis with bordered dressings (RR 8.11, 95% CI 1.03–64.02). A comparison of a bordered transparent dressing and tape found more peripheral venous catheter failure with the bordered dressing (RR 1.84, 95% CI 1.08–3.11) but the relative effect on dislodgement was unclear. ConclusionsThere is no strong evidence to suggest that any one dressing or securement product for preventing peripheral venous catheter failure is more effective than any other product. All of the included trials were small, had high or unclear risk of bias for one or more of the quality elements we assessed, and wide confidence intervals, indicating that further randomised controlled trials are necessary. There is a need for suitably powered, high quality trials to evaluate the newer, high use products and novel – but expensive – securement methods, such as surgical grade glue.

Devices and dressings to secure peripheral venous catheters to prevent complications.

A peripheral venous catheter (PVC) is typically used for short-term delivery of intravascular fluids and medications. It is an essential element of modern medicine and the most frequent invasive procedure performed in hospitals. However, PVCs often fail before intravenous treatment is completed: this can occur because the device is not adequately attached to the skin, allowing the PVC to fall out, leading to complications such as phlebitis (irritation or inflammation to the vein wall), infiltration (fluid leaking into surrounding tissues) or occlusion (blockage). An inadequately secured PVC also increases the risk of catheter-related bloodstream infection (CRBSI), as the pistoning action (moving back and forth in the vein) of the catheter can allow migration of organisms along the catheter and into the bloodstream. Despite the many dressings and securement devices available, the impact of different securement techniques for increasing PVC dwell time is still unclear; there is a need to provide guidance for clinicians by reviewing current studies systematically. To assess the effects of PVC dressings and securement devices on the incidence of PVC failure. We searched the following electronic databases to identify reports of relevant randomised controlled trials (RCTs): the Cochrane Wounds Group Register (searched 08 April 2015): The Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (1946 to March 7 2015); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, March 7 2015); Ovid EMBASE (1974 to March 7 2015); and EBSCO CINAHL (1982 to March 8 2015). RCTs or cluster RCTs comparing different dressings or securement devices for the stabilisation of PVCs. Cross-over trials were ineligible for inclusion, unless data for the first treatment period could be obtained. Two review authors independently selected studies, assessed trial quality and extracted data. We contacted study authors for missing information. We used standard methodological procedures expected by Cochrane. We included six RCTs (1539 participants) in this review. Trial sizes ranged from 50 to 703 participants. These six trials made four comparisons, namely: transparent dressings versus gauze; bordered transparent dressings versus a securement device; bordered transparent dressings versus tape; and transparent dressing versus sticking plaster. There is very low quality evidence of fewer catheter dislodgements or accidental removals with transparent dressings compared with gauze (two studies, 278 participants, RR 0.40; 95% CI 0.17 to 0.92, P = 0.03%). The relative effects of transparent dressings and gauze on phlebitis (RR 0.89; 95% CI 0.47 to 1.68) and infiltration (RR 0.80; 95% CI 0.48 to 1.33) are unclear. The relative effects on PVC failure of a bordered transparent dressing and a securement device have been assessed in only one small study and these were unclear. There was very low quality evidence from the same single study of less frequent dislodgement or accidental catheter removal with bordered transparent dressings than securement devices (RR 0.14, 95% CI 0.03 to 0.63) but more phlebitis with bordered dressings (RR 8.11, 95% CI 1.03 to 64.02) (very low quality evidence). A small single study compared bordered transparent dressings with tape and found very low quality evidence of more PVC failure with the bordered dressing (RR 1.84, 95% CI 1.08 to 3.11) but the relative effects on dislodgement were not clear (very low quality evidence). The relative effects of transparent dressings and a sticking plaster have only been compared in one small study and are unclear. More high quality RCTs are required to determine the relative effects of alternative PVC dressings and securement devices. It is not clear if any one dressing or securement device is better than any other in securing peripheral venous catheters. There is a need for further, independent high quality trials to evaluate the many traditional as well as the newer, high use products. Given the large cost differences between some different dressings and securement devices, future trials should include a robust cost-effectiveness analysis.

Epidural analgesia in the intensive care unit: An observational series of 121 patients

BackgroundEpidural analgesia (EA) has been more investigated during the perioperative period than in the intensive care unit (ICU) setting. Recent studies support beneficial effects for EA beyond analgesia itself. However, data on feasibility and safety are still lacking in the ICU. Our goal was to assess the feasibility and practice of EA in ICU patients. MethodsMulticentre observational study in 3 ICUs over a 10-month period. Goals were to report the incidence of EA-related complications and EA duration. All ICU patients receiving EA were included, whether EA was initiated in the ICU or elsewhere, e.g. in the operating room. Demographics, clinical and biological data were prospectively recorded. Epidural catheter tips were sent to the microbiology laboratory for culture. ResultsOne hundred and twenty-one patients were included (mean age 60years), with mean SOFA and median SAPS II scores of 3.2 and 32, respectively. Reasons for EA initiation included trauma (14%), postoperative pain management after major surgery (42%), and pancreatitis (31%). No EA-related neurologic complication was recorded, and one case of epidural abscess is discussed. No other EA-related infectious complications were observed. Median duration of EA was 11days. Reasons for EA discontinuation included efficient analgesia without EA (60%) and accidental catheter removal (17%). 22% of epidural catheter cultures were positive for skin flora bacteria. ConclusionEA seems feasible in the ICU. Its apparent safety should be further validated in larger cohorts, but these preliminary results may stimulate more interest in the assessment of potential benefits associated with EA in the ICU setting.

Ultrasound-guided internal jugular vein catheterization in critically ill pediatric patients.

PurposeContinuous intravenous access is imperative in emergency situations. Ultrasound-guided internal jugular vein (IJV) catheterization was investigated in critically ill pediatric patients to assess the feasibility of the procedure.MethodsPatients admitted to the pediatric intensive care unit between February 2011 and September 2012 were enrolled in this study. All patients received a central venous catheter from attending house staff under ultrasound guidance. Outcome measures included successful insertion of the catheter, cannulation time, number of cannulation attempts, and number and type of resulting complications.ResultsForty-one central venous catheters (93.2%) were successfully inserted into 44 patients (21 males and 23 females; mean age, 6.54±1.06 years). Thirty-three patients (75.0%) had neurological disorders. The right IJV was used for catheter insertion in 34 cases (82.9%). The mean number of cannulation attempts and the mean cannulation time was 1.57±0.34 and 14.07±1.91 minutes, respectively, the mean catheter dwell time was 14.73±2.5 days. Accidental catheter removal was observed in 9 patients (22.0%). Six patients (13.6%) reported complications, the most serious being catheter-related sepsis, which affected 1 patient (2.3%). Other complications included 2 reported cases of catheter malposition (4.6%), and 1 case each of arterial puncture (2.3%), pneumothorax (2.3%), and skin infection (2.3%).ConclusionThe results suggest that ultrasound-guided IJV catheterization can be performed easily and without any serious complications in pediatric patients, even when performed by visiting house staff. Therefore, ultrasound-guided IJV catheterization is strongly recommended for critically ill pediatric patients.

Percutaneous endoscopic caecostomy for severe constipation in adults: feasibility, durability, functional and quality of life results at 1 year follow-up.

The percutaneous endoscopic ceacostomy (PEC) for antegrade colonic enemas (ACE) has recently been proposed as a less invasive alternative to the Malone procedure in chronic constipated patients. Although the feasibility and safety of this innovative approach has been demonstrated, its functional results remain unknown. The aim of this study was to evaluate constipation symptoms and quality of life 1 year after the PEC placement. From Oct 2007 to Apr 2011, 21 severely constipated patients who required ACE were prospectively included. They underwent endoscopic placement of Chait caecostomy catheter (Cook Medical). Patients completed standardized questionnaires to assess constipation (KESS) and quality of life (GIQLI) scores pre PEC placement and at 1 year. Adverse events and caecostomy use data were also documented. The caecostomy catheter was successfully placed in 19 patients. Complications were all minor, including chronic wound pain (n = 9), serous leakage (n = 7), superficial wound infection (n = 2) and accidental catheter removal (n = 2). Chronic wound pain led to definitive catheter removal in 5 (26 %) patients. One patient died from unrelated cause before the end of the follow-up. At 1 year, 11 (61 %) of the alive patients still performed ACE. During the period of ACE administration, 14 (74 %) patients suspended use of laxatives and retrograde irrigations. Constipation and quality of life scores were available in 15 patients. Median KESS score improved from 25 (12-39) before PEC to 17 (6-34) 1 year after PEC (p < 0.05). Median GIQLI score increased from 69 (25-108) to 95 (48-119) (p < 0.05). PEC placement achieves satisfying functional and quality of life results, and allows approximately 3/4 of patients to suspend laxatives and retrograde enemas. Nevertheless, 1/4 of the patients ask for the PEC removal because of chronic wound pain. In order to improve long-term durability of the device, a better prevention of pain is required.

Placement of long-term hemodialysis catheter (permcath) in patients with end-stage renal disease through external jugular vein.

Background:The number of patients with End-Stage Renal Disease (ESRD) has progressively increased in the population. Kidney transplantation is the specific treatment for such patients; however a majority of patients will require hemodialysis before kidney transplantation. The present study aims to investigate using the external jugular vein (EJV) for Permcath placement in these patients.Materials and Methods:This descriptive and analytical study was conducted in Alzahra Medical Center, Isfahan, in 2012. Catheters were inserted by cutting down the right EJV. The patency rate and potential complications were studied. The obtained data was analyzed using SPSS 21.0.Results:Out of 45 live patients, within three months of surgery, 40 patients (81.6%) had no complications and dialysis continued through Permcath. Permcath Thrombosis occurred in two patients (4.4%). Catheter infection led to the removal of it in one patient (2.2%) 1.5 months after surgery. And accidental catheter removal occurred in one patient.Conclusion:Placement of the permcath in the external jugular vein can be a safe, uncomplicated, and reliable method for patients requiring hemodialysis, and can be a life-saving alternative in patients without accessible internal jugular vein.

Lesser incidence of accidental catheter removal with femoral versus radial arterial access

Lesser incidence of accidental catheter removal with femoral versus radial arterial access

A Prospective Survey of Accidental Catheter and Tube Removal in a Surgical Intensive Care Unit

OZET Objective: Unplanned catheter removal (UCR) in the surgical intensive care unit (sICU) can result in insufficient treatment or monitoring of patients. Our aim was to evaluate the frequency and clinical features of UCRs in sICU patients. Material and Methods: This prospective observational study was run in a 16-bed sICU from 19/09/2009 through 02/03/2010. Four researchers observed the study. The staff in sICU was unaware of observation. Every UCR were classified as either a patient-related incident or health care staff-related incident. Both vascular and non-vascular UPRs were included. A comparison was made between conditions with (pts:≥8) and without (pts:≤7) heavy workload in sICU. Results: Six hundred and eight patients were observed in 1291 patient days. Overall, 92 (6.2%) incidents were recorded. Of these, 72 (4.8%) were patient-related and 20 (1.3%) health care staff-related catheter and tube removals. UCRs occurred more frequently on days with heavy workload compared to other days (9.6% v.s. 3.1%; p<0.001). Subgroup analysis revealed that peripheral vein catheters (p=0.008) and non-vascular tubes (p <0.001) were more likely to be accidentally removed on days with heavy workload compared to other days. Conclusion: Unplanned catheter removal in sICU is prevalent to the extent that it requires close monitoring. Our results suggest that the likelihood of accidental removal increases on days when a high number of patients are admitted.

Lesser incidence of accidental catheter removal with femoral versus radial arterial access

BackgroundArterial catheterization is a frequent procedure in Intensive Care Units (ICUs). Accidental catheter removal (ACR) can cause severe and potentially life-threatening complications such as severe bleeding and vascular damage. Few data are available on accidental arterial catheter removal, and no studies have been found comparing the incidence of ACR between different arterial catheter sites. ObjectiveTo compare the incidence of ACR in femoral and radial arterial catheters. Research designRetrospective study. SettingA polyvalent ICU. SubjectsAll consecutive patients subjected to femoral or radial arterial catheterization. MeasuresThe incidence of ACR per 100 catheter-days between groups was compared using Poisson regression. We considered ACR as the presence of unintended removal produced by the patient or healthcare personnel. ResultsA total of 2419 radial and 1085 femoral arterial catheters were inserted and remained in situ during 14,742 and 6497 days, respectively. We detected 45 cases of ACR with the femoral access and 162 cases with the radial access. The ACR rate was lower with the femoral access (4.1% vs 6.7% in the case of the radial access; p=0.003). Poisson regression analysis confirmed a lower incidence of ACR with the femoral versus the radial access (0.69 vs 1.10 ACR events per 100 catheter-days; OR 0.6, p=0.006, CI95% 0.01-0.83). ConclusionsThe incidence of ACR was found to be lower with the femoral than with the radial arterial catheters. In order to improve patient safety, it could be interesting to exhaustively monitor the incidence of ACR and adopt preventive measures, since ACR can give rise to serious complications.

Peripherally inserted central catheters (PICCs) in the management of oncohematological patients submitted to autologous stem cell transplantation

The aim of our study was to evaluate the feasibility and the safety of the use of peripherally inserted central catheters (PICCs) during autologous peripheral blood stem cell transplantation. Sixty PICCs were inserted in 57 patients (23 females and 34 males; mean age 48, range 19-68 years) and remained in place for an overall period of 1,276 days. All PICCs were positioned by a team of specifically trained physicians and nurses and utilized by specifically trained nurses of our hematology unit. No major insertion-related complications were observed; the only complication during insertion was one local hematoma (1.6 %) due to accidental arterial puncture. Late complications were accidental catheter removal (5 %, 2.3 per 1,000 PICC days), symptomatic catheter-related venous thrombosis (5 %, 2.3 per 1,000 PICC days), and catheter-related bloodstream infection (CRBSI; 3.3 %, 1.5 CRBSI per 1,000 PICC days). The reasons for catheter removal were completion of therapy (42 patients, 70 %), fever of unknown origin (9 patients, 15 %), catheter-related thrombosis (2 patients, 3.3 %), CRBSI (2 patients, 3.3 %), accidental removal (3 patients, 5 %), lumen occlusion (1 patient, 1.6 %), positive culture from peripheral blood (1 patient, 1.6 %), and death (1 patient, 1.6 %). Our data suggest that PICCs are a safe and effective alternative to conventional central venous catheters even in patients particularly prone to infective and hemorrhagic complications such as patients receiving autologous stem cell transplantation.

National Incidence and Impact of Noninfectious Urethral Catheter Related Complications on the Surgical Care Improvement Project

We defined the incidence and health outcomes related impact of noninfectious urethral catheter related complications for the 7 surgical procedures monitored by the Joint Commission as part of the Surgical Care Improvement Project. We performed a cross-sectional analysis of the 2007 National Inpatient Sample (a 20% stratified sampling of nonfederal United States hospitals) using ICD-9-CM procedure and diagnostic codes to identify the incidence of catheter related complications for coronary artery bypass graft, and noncoronary artery bypass graft cardiac surgery, hysterectomy, colon, hip, knee and major vascular surgery. Univariate and multivariate analysis (with a significance level of less than 0.05) was performed to determine if these complications were associated with length of stay, urinary tract infections and/or deaths. A total of 1,420 cases of catheter related complications were identified nationally. The incidence of catheter related complications varied by surgical procedure (average 1 in 528 men and 1 in 5,217 women for all procedures). Univariate analysis revealed that in the presence of catheter related complications, mean length of stay (6 of 7 procedures, range 1.5 to 3.0 days, p <0.05) and urinary tract infection (5 of 7 procedures, absolute range 6.9% to 11.8%, p <0.05) were statistically increased for most procedures. Multivariate analysis demonstrated a significant association between catheter related complications, and increased length of stay (range 1.5 to 3.5 days, p <0.05) and urinary tract infection (OR 2.4-6.8, p <0.05) for 5 and 6 of 7 procedure types, respectively, but not mortality rate (0 of 7 procedures). Catheter related complications are reported rarely, but are associated with increased length of stay and urinary tract infection rates for patients in the Surgical Care Improvement Project.

Promoting Major Pediatric Surgical Care in a Low‐Income Country: A 4‐Year Experience in Eritrea

Access to pediatric surgical care in many sub-Saharan African countries is strongly limited by lack of medical facilities, adequate transport system, and trained medical and nursing manpower. The mortality rate for major congenital abnormalities remains extremely elevated in this area of the world. Strong efforts have been spent during the past decades to elevate the level of pediatric surgery standards in these countries through cooperation programs acting through periodical medical missions or supporting local medical teaching institutions. This is a report of a partnership between an Italian Medical Institution and the Eritrean Ministry of Health with the goal to improve pediatric surgical standard of care in the country. During the past 4 years, teams composed of two pediatric surgeons, a pediatric anesthetist, and a pediatric nurse regularly visited the Orotta Medical and Surgical Referral Hospital of Asmara (Eritrea) to offer modern surgical treatment to children with major congenital abnormalities and to offer academic training to local medical and nursing staff. The team worked in local health structures. A total of 714 patients have been visited and 430 surgical procedures have been performed during 35 weeks of clinical work. Among them were 32 anorectal malformations, 11 Hirschsprung's disease cases, 8 bladder extrophies, and many other major surgical problems, such as congenital intestinal obstructions, obstructive uropathies, and solid tumors. The standard of care has been based on the principle of researching sustainable solutions. Surgical options and timing of each procedure have been decided to reduce hospitalization and the recourse to temporary stomas, indwelling catheterization, and prolonged intravenous feeding. Posterior sagittal anorectoplasties (PSARP) and posterior vagino-anorectoplasty (PSVARP) were performed for anorectal malformations, introducing minimal technical variants to reduce the need for postoperative nursing. Endorectal pull-through of functional stoma was the treatment of choice for patients with Hirschsprung's disease because frozen sections were not possible. Eight late-referred bladder extrophy cases were all managed by internal diversion (Mainz II pouch). Solid abdominal tumors always came to observation weeks or months after the first symptoms appeared. No CT scan was available and indications of surgery were based on clinical symptoms only. Only 11 of 18 cases were resectable, and only 5 of them with favorable histology survived, 2 after adjuvant therapy abroad. A large number of hypospadias were observed at the mean age of 4.5 years. Failures of previous attempts at correction were frequently found. The postoperative complications rate progressively decreased with the use of dripping stents to avoid the risk of accidental catheter removal or kinking. On the basis of our experience, major pediatric surgery in many under-resourced areas of sub-Saharan Africa can be developed, taking care to adapt surgical options to local conditions. Late referral of many congenital abnormalities, the impact of local culture, difficulties to establish regular follow-up, and shortage of facilities and medical devices must always be kept in mind before transferring modern protocols of management. Strong efforts have been devoted to train local medical and nursing staff to establish pediatric surgical manpower to cope with a still largely unanswered demand of care in this area of Africa.

Early Mobility and Walking for Patients with Femoral Arterial Catheters in Intensive Care Unit: a Case Series

ABSTRACT Patients with femoral arterial catheters for hemodynamic monitoring are sometimes placed on bed rest because of the anatomical location and perceived risk of catheter-related complications associated with mobility. This practice subjects these patients to the well known adverse effects of inactivity on functional mobility and functional outcomes. Because of limited evidence to link mobility with femoral artery displacement or damage, this practice may be unwarranted and may add to the treatment burden of the patient in the intensive care unit. The purpose of this study was to explore whether physical therapy-directed mobilization of patients with femoral arterial catheters resulted in adverse events. A retrospective case series was undertaken on patients in a 40-bed cardiovascular and thoracic intensive care unit. The list of potential catheter-related adverse events investigated included bleeding at the femoral arterial catheter site, accidental catheter dislodgement and/or removal, non-functioning catheter after activity event, and acute limb ischemia within 24 hours. The 30 patients identified for the study underwent 47 physical therapy sessions with a total of 156 activity events including sitting on the side of the bed, standing at bedside, transfers to a regular chair or a stretcher chair, and walking. No femoral arterial catheter-related adverse events that could be attributed to participation in physical therapy were documented in either the nursing or physical therapy notes. The data from this single center retrospective case series suggest that early mobility and walking activities do not affect femoral arterial catheters used for hemodynamic monitoring and orders for bed rest may unnecessarily add to symptom burden faced by these patients.