Deep Venous Catheter Research Articles

Epidemiology and resistance profiles of Enterobacterales in a tertiary care hospital in Lebanon: a 4-year retrospective study.

Antimicrobial resistance (AMR) is a worldwide problem that threatens treatment effectiveness against the most serious bacterial infections. AMR in Enterobacterales is highly prevalent in Lebanon. However, recent reports regarding the distribution of Enterobacterales and related antimicrobial susceptibility are scarce. In this retrospective study at the Lebanese Hospital Geitaoui Medical Center in Lebanon, all data regarding culture specimens from urine, blood, sputum, deep tracheal aspirate, broncho-alveolar lavage, wounds, surgical sites, tissue, body fluids, and central venous catheter that were positive for at least one of the 4 bacterial isolates (Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae and Proteus mirabilis) were collected. All susceptibility testing was performed according to the Clinical and Laboratory Standards Institute guidelines. A total of 4283 non-duplicate Enterobacterales were isolated during the study period (January 2017 to December 2020). Urine was the most common site of infection. E. coli was the most detected isolate as well as the leading pathogen in urine, wounds and surgical sites, and blood. Regarding antimicrobial susceptibility, the mean susceptibility to third generation cephalosporins was 55.53% and a mean extended-spectrum β-lactamases production of 31.2% was measured in E. coli. Mean carbapenem susceptibility was the lowest in K. pneumoniae and E. cloacae. The lowest mean susceptibility to fluoroquinolones was detected in E. coli isolates. This study identified the predominance of E. coli among Enterobacterales in Lebanese patients, with the urinary tract being the most common site of infection and underlined the high rates of AMR in Enterobacterales in Lebanon.

Comparison of hospitalization cause and risk factors between patients undergoing hemodialysis and peritoneal dialysis

This retrospective study was designed to compare the cause of hospitalization and influencing factors between patients undergoing hemodialysis (HD) and peritoneal dialysis (PD). Baseline data and laboratory parameters of 192 dialysis patients (92 HD patients and 100 PD patients) were compared. Quantitative parameters with normal distribution were assessed using independent t-test or analysis of variance (ANOVA). Quantitative parameters with non-normal distribution were assessed by non-parametric test. Qualitative data were statistically compared using χ2 test. The number of patients with urban employee medical insurance (88 HD patients and 60 PD patients) and rural cooperative medical care (12 HD patients and 40 PD patients) significantly differed (P < .01). The hospitalization rate of PD patients was significantly higher than that of HD counterparts. The average length of hospital stay of PD patients was 10 days, remarkably longer than 8 days of HD patients (P < .01). The primary cause of hospitalization for HD patients was infection-related complications, followed by cardiovascular, cerebrovascular complications and dialysis access disorders. The primary cause of hospitalization for PD patients was infection-related complications, followed by dialysis access disorders, cardiovascular, and gastrointestinal complications. Compared with the HD group, the levels of hemoglobin, serum albumin, alkaline phosphatase, intact parathyroid hormone were significantly decreased, whereas serum urea nitrogen, serum creatinine, phosphorus levels and cardiothoracic ratio were remarkably increased in the PD group (all P < .01). The hospitalization rate of PD patients is relatively higher, and the length of hospital stay is longer. Extensive attention and efforts should be delivered to enhance the understanding of disease and lower the risk of complications for patients.

EMERGING DATA FOR CANCER ASSOCIATED THROMBOSIS TREATMENT

Venous thromboembolism (VTE) is a common complication in patients with malignancies,resulting in deep vein thrombosis, pulmonary embolism and central venous catheter VTE, and is responsible for high morbidity and mortality (1). The prevalence of cancer-associated thrombosis is increasing because of multiple factors, including longer patient survival, anticancer therapies, increased detection of incidental VTE during surveillance imaging, and wider use of central venous catheters. Anticoagulant therapy with low-molecular-weight heparins (LMWHs) was the standard of care for the treatment of cancer-associated thrombosis, with vitamin K antagonists providing a secondary treatment option, until direct oral anticoagulants (DOAC) emerged as alternative first-line treatment options in 2016 (2). Rivaroxaban, Edoxaban and Apixaban are recommended as initial treatment in patients with cancer-associated thrombosis who are not at high risk of gastrointestinal or genitourinary bleeding (3). LMWHs and Fondaparinux are still recommended for prophylaxis of VTE in medically-treated patients with cancer. Rivaroxaban and Apixaban can be used selectively for thromboprophylaxis in patients with malignancies at high risk of VTE, for example in patients with pancreatic cancer or myeloma (4,5). Anticoagulant choice should incorporate a personalised medicine approach that considers cancer type, VTE and bleeding risk factors, drug–drug interactions (DDI), and patient preferences. Patients with cancer often experience narrow therapeutic index polypharmacy and undergo treatment for several simultaneous comorbidities. In this setting the risk of DDI is high in particular during therapy with tyrosine kinase inhibitors (6). Concerns on DDI management include decreased efficacy and bleeding risk. In general, DOAC use is not advisable in combination with drugs that are strong inhibitors of both P-gp and/or CYP3A4 for high bleeding risk and in combination with strong inducers of Pgp and/or CYP3A4 that could markedly reduce DOAC plasma levels. Routine use of plasma level measurements for DOAC, only available in few laboratory centres, is not currently recommended (7). Nevertheless it has recently become increasingly clear that clinicians need to assess the anticoagulant status of a patient receiving anticancer therapies. The global coagulation Test of thrombin generation (TGT) a sensitive method to assess the anticoagulant therapy, provides a global measure of anticoagulant effect by measuring the inhibition of formation of thrombin (FIIa), a common endpoint for both LMWH and FXa inhibitors (8). Furthers studies are warranted to better define the future role of this coagulation test in this subgroup of patients.

Rho-kinase inhibition improves haemodynamic responses and circulating ATP during hypoxia and moderate intensity handgrip exercise in healthy older adults.

Skeletal muscle haemodynamics and circulating adenosine triphosphate (ATP) responses during hypoxia and exercise are blunted in older (OA) vs. young (YA) adults, which may be associated with impaired red blood cell (RBC) ATP release. Rho‐kinase inhibition improves deoxygenation‐induced ATP release from OA isolated RBCs. We tested the hypothesis that Rho‐kinase inhibition (via fasudil) in vivo would improve local haemodynamic and ATP responses during hypoxia and exercise in OA. Healthy YA (25 ± 3 years; n = 12) and OA (65 ± 5 years; n = 13) participated in a randomized, double‐blind, placebo‐controlled, crossover study on two days (≥5 days between visits). A forearm deep venous catheter was used to administer saline/fasudil and sample venous plasma ATP ([ATP]V). Forearm vascular conductance (FVC) and [ATP]V were measured at rest, during isocapnic hypoxia (80% SpO2), and during graded rhythmic handgrip exercise that was similar between groups (5, 15 and 25% maximum voluntary contraction (MVC)). Isolated RBC ATP release was measured during normoxia/hypoxia. With saline, ΔFVC was lower (P < 0.05) in OA vs. YA during hypoxia (∼60%) and during 15 and 25% MVC (∼25–30%), and these impairments were abolished with fasudil. Similarly, [ATP]V and ATP effluent responses from normoxia to hypoxia and rest to 25% MVC were lower in OA vs. YA and improved with fasudil (P < 0.05). Isolated RBC ATP release during hypoxia was impaired in OA vs. YA (∼75%; P < 0.05), which tended to improve with fasudil in OA (P = 0.082). These data suggest Rho‐kinase inhibition improves haemodynamic responses to hypoxia and moderate intensity exercise in OA, which may be due in part to improved circulating ATP. Key points Skeletal muscle blood flow responses to hypoxia and exercise are impaired with age. Blunted increases in circulating ATP, a vasodilator, in older adults may contribute to age‐related impairments in haemodynamics.Red blood cells (RBCs) are a primary source of circulating ATP, and treating isolated RBCs with a Rho‐kinase inhibitor improves age‐related impairments in deoxygenation‐induced RBC ATP release.In this study, treating healthy older adults systemically with the Rho‐kinase inhibitor fasudil improved blood flow and circulating ATP responses during hypoxia and moderate intensity handgrip exercise compared to young adults, and also tended to improve isolated RBC ATP release.Improved blood flow regulation with fasudil was also associated with increased skeletal muscle oxygen delivery during hypoxia and exercise in older adults.This is the first study to demonstrate that Rho‐kinase inhibition can significantly improve age‐related impairments in haemodynamic and circulating ATP responses to physiological stimuli, which may have therapeutic implications.

Effect of Applying Improved Fixation Method in Nursing of Deep Venous Catheter

Effect of Applying Improved Fixation Method in Nursing of Deep Venous Catheter

Dalbavancin in Real Life: Economic Impact of Prescription Timing in French Hospitals.

IntroductionThe extended half-life of dalbavancin justifies a once-a-week dosing schedule and is supposed to favour early discharge. These advantages may therefore compensate for the cost of dalbavancin, but no real-life assessment has been conducted to date. We aimed to assess the real-life budget impact of dalbavancin through its impact on the length of stay in French hospitals.MethodsA multicentre cohort based on the French registry of dalbavancin use in 2019 was compared to the French national discharge summary database. Lengths of stay and budget impact related to the infection type, the time of introduction of dalbavancin, the type of catheter and patient subgroups were assessed. An early switch was defined when dalbavancin was administered as the first or second treatment and within less than 11 days of hospitalization.ResultsA total of 179 patients were identified in the registry, and 154 were included in our study. Dalbavancin was mostly used for bone and joint infections (56.0%), infective endocarditis (19.0%) and acute bacterial skin and skin structure infections (6.0%). When compared to the data for similar patients in the national database, the length of stay was almost always shorter for patients treated with dalbavancin (up to a reduction of 13 days). The budget impact for dalbavancin was heterogeneous but frequently generated savings (up to 2257.0 €). Early switching (within less than 11 days) was associated with savings (or lesser costs), with even greater benefits within 7 days of hospitalization. Patients who required a deep venous catheter as well as the most severe patients benefited the most from dalbavancin.ConclusionOur study confirms that dalbavancin is associated with early discharge, which can offset its cost and generate savings. The greatest benefit is achieved with an early switch.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-021-00577-6.

346. Head to Toe Imaging of Complications and Sequelae of COVID- 19 and COVID-19 Vaccination

BackgroundCOVID 19 is associated with a hypercoagulable state with cytokine storm syndrome and thrombocytopenia leading to complications across various systems. COVID-19 infection, its treatment, resultant immunosuppression, and pre-existing comorbidities have made patients vulnerable to secondary infectionsMethodsWe systematically reviewed COVID-19 cases between Jan to May 2021 for pulmonary and extrapulmonary complications. Patients with recent COVID-19 vaccination and neurological symptoms were also included.Figure 1. “Black turbinate” sign of mucormycosis Contrast enhanced coronal T1 FS images of paranasal sinuses shows necrotic non-enhancing right superior and middle turbinates (*) with extension into the right orbital fat.FIGURE 2 - A composite image of Coronal CT of upper abdomen in arterial phase and lung bases in lung window showing wedge showing right renal infarcts (line arrow) due to inferior polar artery thrombosis and ground glass opacities (solid arrow) in lung bases. Results Neurological complications: Neurological complications include ischemic and haemorrhagic strokes. Other complications are encephalopathy, encephalitis, Guillain-Barré syndrome, acute hemorrhagic necrotizing encephalopathy. Demyelination and radiculopathies are seen as post vaccination complications. Mucormycosis: Unprecedented high rate of invasive fungal sinusitis in association with COVID -19 is reported from the Indian subcontinent. This has a propensity for intra orbital and intracranial extension. COVID -19 associated coagulopathy: COVID -19 is a pro-inflammatory hypercoagulable state. Pulmonary thromboembolism, deep venous thrombosis and catheter related thrombosis are well documented. Cardiac complications: Cardiac manifestations include Myocardial Injury with non-obstructed coronary arteries (MINOCA), myocarditis, myocardial ischemia, cardiomyopathy. Pulmonary complications and sequelae of COVID -19: Progression of lung injury to ARDS during the initial phase and fibrosis of parenchyma in the recovery phase. Spontaneous pneumomediastinum, pneumatoceles and pneumothorax and secondary infections are identified in our study. COVID- 19 associated gastrointestinal complications: Patients evaluated for renal colic, pancreatitis, cholecystitis showed, ground glass opacities or subpleural bands in typical Covid-19 distribution. COVID-19 may lead of acute kidney and bowel injury due to arterial thrombosis. COVID - 19 associated myonecrosis: Ischemia of the small caliber vessels may result in myonecrosis.FIGURE 3 - Coronal STIR image shows thickened and hyperintense trunks and divisions of the right brachial plexus suggestive of plexopathy in a COVID -19 patient with H/O recent COVID-19 vaccination. Figure 4. Axial CT chest section in lung window showing pneumothorax (white arrow) and pneumatocele ( grey arrow) with peripheral ground glass opacities and consolidations in both lungs. ConclusionAwareness of these unusual manifestations will facilitate an early diagnosis, improve management and help reduce morbidity and mortalityDisclosures All Authors: No reported disclosures

A Comparison of Lower Limb Peripherally Inserted Central Catheter and Deep Venous Catheterisation.

To compare the clinical application effects of peripherally inserted central catheter (PICC) and deep venous catheters placed through the lower limbs in adults with malignancy obviating the use of upper limb PICC. Descriptive study. Department of Oncology, Beijing Shijingshan Hospital, Capital Medical University, Beijing, China between February 2017 and February 2019. The patients enrolled in this study were assigned to PICC under ultrasound guidance group and deep venous catheterisation group. The inclusion criteria were patients with advanced malignant tumor after bilateral breast cancer lymphadenectomy or superior vena cava obstruction syndrome; bedridden patients; and patients without mental disorders; who could understand the content of this study and agreed to participate in this study. Patients with high-risk thrombosis and venous thrombosis of lower limbs were excluded.The success rate of one-time catheterisation, the length of catheterisation puncture time, the number of catheterisations, and the occurrence of catheter-related complications of the two groups were compared. Ultrasound-guided PICC through the lower limbs had a higher success rate than deep venous catheterization (84.6% vs. 42.9%, p=0.046). The average length of puncture time in adults with PICC through the lower limbs under ultrasound guidance was shorter than that in the femoral vein group (24.69 ± 4.35 vs. 29.14 ± 6.02, p=0.038). No catheter-related infection was found in the two groups of patients. The indications for PICC through the lower limbs in adults include patients with advanced malignant tumor after bilateral breast cancer lymphadenectomy or superior vena cava obstruction syndrome, and mainly bedridden patients. This technique has certain advantages over deep venous catheterisation and is an effective choice for venous access. Key Words: Lower limb PICC, Deep venous catheterisation, Advanced malignant tumor, Bedridden.

Unfractionated Heparin (UFH) For Prevention of Central Venous Catheter Thrombotic Complications in Children: A systematic review and meta-analysis

Abstract Objective To determine the efficacy of unfractionated heparin in reducing central venous catheter-related deep venous thrombosis and/or catheter thrombotic occlusion in children by systematically searching the literature and conducting a meta-analysis study. Methods Four electronic databases (PubMed, Google Scholar, Elsevier’s thrombosis journal, and the Cochrane Central Register for Controlled Trials) were searched for journal peer-reviewed articles published in the period from Jan 2000 to Dec 2018. The search criteria included observational studies, and randomized controlled trials on patients aged 0–18 years with central venous catheters (CVC), which compare between the effect of UFH (flushes, lock solutions, continuous infusion, and heparin bonded catheter) and no prophylaxis (Normal saline flush or no treatment) for the prevention of CVC thrombotic complications (CVC-related deep venous thrombosis (DVT) and/or catheter thrombotic occlusion). Two authors independently reviewed and identified the eligible studies, which were assessed for study methodology including bias, and extraction of unadjusted data whenever available. To pool data from eligible studies, the meta-analysis was performed on RevMan version 5.3. Odds ratios were generated with the corresponding 95% CI through the random-effect model. Results Of the 413 articles identified, only eight studies were eligible with 1380 patients. Our results revealed that UFH was significantly superior on control group in reducing thrombotic occlusion and/or CVC-related DVT (odds ratio 0.39, 95% CI: 0.19:0.8) (p 0.01). Conclusion The published data support the hypothesis that using UFH as a thromboprophylaxis may significantly reduce catheter thrombotic complication in pediatric patients with CVC.

Role of Fine Management in Maintenance of Deep Venous Indwelling Catheter in Hemodialysis Patients

Objective: This paper mainly explores the effect of fine management application in maintenance of deep venous indwelling catheter in hemodialysis patients. Methods: 150 hemodialysis patients with deep venous catheter indwelling in our hospital from December 2019 to September 2020 were divided into routine group and study group. The routine group was given routine nursing, and the study group was given fine management nursing. The nursing effect of the two groups was analyzed. Results: After nursing intervention, the incidence of complications in the study group was 14.66%, which was lower than that in the conventional group (53.33%), and the nursing compliance in the study group (98.66%) was higher than that in the conventional group (89.33%), all P &lt; 0.05. Conclusion: Fine management plays a significant role in the maintenance of deep venous indwelling catheter in hemodialysis patients, which can reduce the occurrence of complications.

The axillary vein puncture can reduce the incidence of central venous catheter-related bloodstream infection

Objective To compare the effects of various interventions on the incidence of central line-associated bloodstream infection (CLABSI) . Methods The clinical data of 218 patients with central venous catheterization were retrospectively analyzed. Infected patients were treated as CLABSI group and non-infected patients as control group. Results Of the 218 patients, 24 patients were developed CLABSI. There was no significant difference in sex, age, primary infection status and puncture site between CLABSI group and control group. Univariate analysis showed that axillary vein puncture could significantly reduce the incidence of CLABSI (P=0.028), and the infection rate of axillary vein puncture per 1000 days under B-ultrasound was significantly reduced by 0.93‰. The average indwelling days of deep venous catheter in patients with pulse puncture were significantly longer than those in other groups (47.32 days vs 19.90 days). The average indwelling days in patients with axillary vein puncture positioned by B ultrasound were longer than those in patients with other parts of vein puncture positioned by B ultrasound (P < 0.05). Logistic multiple regression analysis showed that the main risk factors for CLABSI were anatomically located puncture (P = 0.031) and non-axillary venous catheterization (P = 0.068). Conclusions Choosing axillary vein as the position of deep venous catheterization and using ultrasound-guided central venous puncture can reduce the incidence of CLABSI and prolong the average catheterization time. Key words: Axillary vein; Ultrasound-guided; Central line-associated bloodstream infection; Case control study

The effect of indwelling catheter care risk assessment on unplanned extubation and nursing outcome in patients undergoing hepatobiliary surgery

Objective To explore the effect of indwelling catheter care risk assessment on unplanned extubation and nursing effects in patients undergoing hepatobiliary surgery. Methods A total of seventy-two patients undergoing routine care for liver and gallbladder surgery from September 2015 to September 2016 in this hospital were selected as the control group.In addition, 72 cases of liver and gallbladder surgery patients admitted by the hospital from October 2016 to October 2017 for nursing risk assessment were selected as the observation group.The unplanned extubation and nursing effect were compared between the two groups. Results The rate of T tube, gastric tube, abdominal drainage tube, deep venous catheter and unplanned catheter extubation in the observation group was lower than that in the control group, and the difference was statistically significant (P<0.05). The rate of catheter blockage, catheter folding, catheter slip and complaint in the observation group was lower than that in the control group, and the nursing satisfaction was higher than that in the control group, the difference was statistically significant (P<0.05). Conclusions The application of indent catheter nursing risk assessment in patients with hepatobiliary surgery can effectively reduce the rate of unplanned extubation and improve the nursing effect, which is worthy of clinical promotion. Key words: Indwelling catheter; Nursing risk assessment; Hepatobiliary surgery; Unplanned extubation; Nursing effect

PICC management led by technicians: Establishment of a cooperation program with radiologists and evaluation of complications

PurposeThe purpose of this study was to evaluate a cooperation program in order to compare incidence of complications after peripherally inserted central catheter (PICC) placement between radiologists and technicians. Materials and methodsPICC placement technique was standardized with ultrasound-guided puncture and fluoroscopic guidance. Numbers of PICC delegated to technicians, and PICC placement difficulties, were prospectively recorded for the whole study population whereas complications such as PICC infection, deep venous thrombosis and catheter occlusion were prospectively recorded until PICC removal for a subgroup of patients included during one month. ResultsA total of 722 patients had PICC placement. There were 382 men and 340 women with a mean age of 66.8±15.8 (SD) years (range: 18–94years); of these, 442/722 patients (61.22%) were included in the cooperation program with 433/722 patients (59.97%) who effectively had PICC placement by technicians and 289/722 (40.03%) by radiologists. Technicians needed radiologists’ help for 23/442 patients (5.20%) including 6 failed PICC placement subsequently performed by radiologists. Twenty complications (20/77; 26%) were recorded in the subgroup of 77 patients studied for complications. No differences in complications rate were found between the 33 patients who underwent PICC placement by radiologists (6/33; 18%) and the 44 patients who underwent PICC placement by technicians (14/44; 32%) (P=0.296). Complications included 8 PICC-related infections (8/77; 10.4%), 3 deep venous thromboses (3/77; 3.9%) and 9 catheter occlusions (9/77; 11.7%). ConclusionPICC placement led by technicians is feasible and safe without statistical difference in terms of complications compared to PICC placement made by radiologists.

Exploration of high-risk factors for pulmonary embolism in patients undergoing postoperative anti-thrombotic therapy among gynecologic oncology surgery: a retrospective study.

The aim of this study was to find the high-risk factors of patients undergoing postoperative anti-thrombotic therapy that had a pulmonary embolism (PE). In this retrospective analysis, a total of 35 patients with gynecologic oncological surgery were included from April 3, 2013, to January 12, 2018. Variable characteristic selection (Boruta's method), binary logistic regression (Fifth's method), and elastic network analysis were used to establish models and screen the high-risk factors. The decision curve analysis (DCA) was used to discriminate differences on these models as well. Three models were established, and the clinical efficiency of these three models was similar. Within the risk range of 0.1-0.3, the elastic network model was shown to have a good net benefit rate. The preoperative cholesterol levels were selected in all three models. The high-risk factors that were selected in both models were operative time, preoperative fibrinogen level, crystal rehydration on the day of surgery in the ward, a preoperative low-density lipoprotein (LDL) level, deep venous catheters, and presence of colloids. Other factors included crystal fluid intake during surgery, age, and chemotherapy before surgery. Positive anti-thrombotic therapy may be required among the patients with increased risk and further research might be needed to verify high-risk factors.

The clinical features of patients: transfered by "Qilu " interhospital transfer center

Objective To explore new models for interhospital transfer and provide theoretical basis for the interhospital transfer system construction through analyzing the clinical features of the patients transfered by interhospital transfer center. Methods Totally 258 patients aged over 18 years who were transferred to or from Qilu Hospital of Shandong University from August 2014 to December 2016 were analyzed. The data including sex, age, transport index, modified early warning score (MEWS) and outcome of patients with successful transport were collected. According to the results, the transferred patients were divided into the improved group and the non-improved group, and the differences of the above indicators between the two groups were analyzed. In the numerical variable analysis, Student’s t test or Mann-whitney non-parametric test was applied, and the categorical variable was applied with χ2 test. The correlation between clinical indicators and outcomes of the patients was analyzed by logistic regression analysis. Results The total transfer success rate was 98.5%. The transported male patients were more than female patients. Patients transferred to Qilu Hospital were mainly diagnosed with nervous system disease, trauma and circulatory system disease, and patients transferred from QiLu Hospital were respiratory disease, circulatory system disease, and nervous system disease. Tracheal intubation, tracheotomy, and invasive mechanical ventilation rates were 11.9%- 22.2%. The patients ratio of transferred from Qilu Hospital with vasoactive drugs and the ratio of patients with deep venous catheter were three times and five times than those transferred to Qilu Hospital. Eighty-one percent patients transferred to Qilu Hospital recovered, and 45.5% patients transferred from the hospital recovered. The age, heart rate, MEWS score, length of stay, ICU ratio, mechanical ventilation ratio and tracheal intubation ratio were significantly different between the improved group and the non-improved group (P<0.05). Among the critically patients transferred to ICU, the length of stay was correlated with the outcome of the improvement. (OR=1.213, 95%CI : 1.085-1.357). Conclusions Qilu Interhospital Transfer Center has a high success rate and high recovery rate of patients, and can be a new model for the construction of interhospital transfer system. Key words: QiLu model; Transport Center; New model; Inter-hospital transport; Remote; Clinical features; Efficiency; System construction; Theoretical basis.

Comprehensive Nursing Intervention for the Management of a Tip-conductive Peripherally Inserted Central Catheter in Oncology Patients

Peripherally inserted central catheters (PICCs) play a great role in infusion of chemotherapy, parenteral nutrition, and intravenous fluid. It has the advantages of safety, convenience, long duration and low infection rate compared to central venous catheters (CVCs), becoming more and more popularized in clinical application. However, the clinical application of PICCs also causes complications, such as local infection, phlebitis, deep venous thrombosis, catheter malposition and breakage as well as liquid extravasation. The total complications rate varies mainly for three aspects: patients-related, catheter-related and operation-related. Disease types and severity of patients have been deeply researched. More concerns have been paid on the technology of catheter and operation to decrease the related complications. The intracavitary electrocardiogram (IC-ECG) method has been developed to be a safe, accurate and highly cost effective method. However, the traditional IC-ECG method is complicated and time consuming. Many researches have carried out to overcome the shortcomings of traditional methods. The tip-conductive PICC method came into being. The application of tip-conductive PICC greatly increases the first-attempt successful tip location and the tip location satisfactory. In this article, we reviewed the principle and characteristics of tip-conductive PICC, and comprehensive nursing care intervention including puncture, infection prevention, mechanical phlebitis, catheter blockage and catheter heterotopia and rupture.

Clinical retrospective analysis of Klebsiella pneumoniae bloodstream infection

Objective To explore the clinical characteristics, drug resistance and prognosis of Klebsiella pneumoniae bloodstream infection (KP-BSI), and to analyze the risk factors of death and drug resistance. Methods The clinical data of hospitalized patients with KP-BSI from April 2015 to April 2017 in Huashan Hospital were retrospectively analyzed. Continuous variables were compared using t test. Categorical variables were compared using χ2 test or Fisher exact test. The independent risk factors for death were determined by logistic regression model. Results The majority of the 74 patients with KP-BSI were male (67.6%) and elderly patients (78.4%). Nosocomial infection occurred in 58 cases (78.4%) and a total of 24 (32.4%) cases died. The patients were widely distributed in various departments of the hospital. The first was the Department of Infectious Diseases (29.7%), followed by the intensive care unit (23.0%). The patients were often complicated with various underlying diseases and the most common was pulmonary infection (56.8%). There were 45 (60.8%) multiple drug resistance (MDR) strains and 29 (39.2%) Carbapenems resistant Klebsiella pneumoniae (CRKP) strains. There were significant differences of nosocomial infections (χ2=4.655, P=0.031), deep venous catheters (χ2=5.432, P=0.02), and invasive mechanical ventilation (χ2=7.630, P=0.006) between MDR and non-MDR patients. Deep venous catheters (χ2=5.923, P=0.015), invasive mechanical ventilation (χ2=16.845, P=0.000), other catheters (χ2=4.009, P=0.045) and surgery (χ2=3.910, P=0.048) were all significantly different between CRKP and non-CRKP patients. APACHE Ⅱ scores were performed in all patients. The average APACHE Ⅱ score was 8.74±5.32 of the 50 cases (67.6%) in the survival group and that was 16.46 ± 6.62 of the 24 cases (32.4%) in the death group. The APACHE Ⅱ score in the survival group was significantly lower than that in the death group. The difference was statistically significant (t=5.091, P=0.000). APACHE Ⅱ≥15 was the independent factor of death (B =-2.708, P=0.000). Conclusions The situation of drug-resistant KP-BSI is severe in the clinic. According to the clinical data, nosocomial infections, invasive mechanical ventilation and deep venous catheters may be the risk factors for MDR bloodstream infection. Deep venous catheters, invasive mechanical ventilation, other catheters and surgery may be the risk factors for bloodstream infection with CRKP. APACHEⅡ≥15 is the independent risk factor for death. The evaluation of APACHE Ⅱ score may predict the prognosis of patients with bloodstream infection. Key words: Klebsiella pneumoniae; Risk factors; Bloodstream infection; Clinical features

Citrate: How to Get Started and What, When, and How to Monitor?

In most of the case, regional citrate anticoagulation is using diluted citrate around 1% depending on the types used in clinical practice. Diluted citrate is much more safer when compared to highly concentrated citrate around 4% or even more. In clinical practice, trisodium citrate is used in high concentration (around 30%) as a bactericidal agent with anticoagulant properties for locking deep venous catheters used in hemodialysis (HD; close to 25–30% of citrate). In this review article, buffer and anticoagulant potential of citrate are discussed during renal replacement therapy in critically ill patients with particular focus on the practical approach at the bedside.

Rho‐kinase Inhibition Improves Hemodynamic Responses and Circulating ATP During Hypoxia and Exercise in Healthy Older Adults

Circulating ATP is a potent vasodilator believed to assist in the matching of tissue oxygen delivery to oxygen demand. Older adults have impaired skeletal muscle hemodynamic responses to hypoxia and exercise and blunted increases in circulating ATP during these stimuli, which may be due to reduced deoxygenation‐mediated red blood cell (RBC) ATP release. We recently demonstrated that treatment of isolated RBCs with a Rho‐kinase inhibitor improves RBC membrane deformability and restores ATP release from RBCs of older adults. Thus, the goal of the present study was to test the hypothesis that in vivo Rho‐kinase inhibition would improve hemodynamic responses and circulating ATP during hypoxia and exercise in older adults. Healthy young (Y; 27 ± 1 years; n = 5) and older (O; 67 ± 2 years; n = 7) adults participated in a double‐blind, randomized, placebo‐controlled, crossover design study on two days (≥ 5 days between visits). A deep venous catheter in the forearm was used to administer the placebo (100 ml saline/60 min) or the Rho‐kinase inhibitor (60 mg fasudil/60 min) and to sample blood for plasma [ATP]. Forearm vascular conductance (FVC; mean arterial pressure from finometry and forearm blood flow (FBF) from Doppler ultrasound) was calculated at rest, during 5 min of isocapnic hypoxia (80% SpO2), and during graded intensity rhythmic handgrip exercise at 5, 15 and 25% of maximum voluntary contraction (MVC; 4 min per workload). Plasma [ATP] was measured at rest and at the end of each condition, and RBCs were isolated to measure ATP release in response to normoxic (PO2 ~120 mmHg) and hypoxic (PO2 ~24 mmHg) stimuli using the luciferin‐luciferase technique. In the placebo trial, the increase in FVC during hypoxia was ~50% lower in O vs Y, and during exercise the greatest age impairment occurred at 25% MVC (266.4 ± 27.6 vs 394.9 ± 35.0 ml/min/100 mmHg; P &lt; 0.05). Plasma [ATP] and ATP effluent (FBF × [ATP]; an index of the total circulating rate of ATP) tended to be lower in O vs Y during hypoxia (75.3 ± 16.6 vs 100.6 ± 18.8 nmol/L and 2.3 ± 0.7 vs 3.1 ± 0.7 nmol/min, respectively) and were lower at 25% MVC (92.8 ± 12.6 vs 168.7 ± 31.5 nmol/L and 28.1 ± 4.9 vs 66.9 ± 9.6 nmol/min, respectively; P &lt; 0.05). The increase in isolated RBC ATP release from normoxia to hypoxia was also impaired in O vs Y (21.4 ± 17.2% vs 77.8 ± 13.3%; P &lt; 0.05). Compared to control, fasudil in O improved FVC during hypoxia (35.2 ± 3.7 ml/min/100 mmHg; P &lt; 0.05) and 25% MVC exercise (324.4 ± 21.7 ml/min/100 mmHg; P &lt; 0.05), and abolished the impairment vs Y. Fasudil tended to improve plasma [ATP] and ATP effluent during hypoxia in O (98.7 ± 29.0 nmol/L and 3.34 ± 0.8 nmol/min), and during 25% MVC exercise (152.2 ± 26.7 nmol/L and 48.3 ± 6.7 nmol/min). Fasudil also tended to improve isolated RBC ATP release (55.6 ± 17.5% vs 21.4 ± 17.2%) and abolished the impairment vs Y. These preliminary data suggest that in vivo Rho‐kinase inhibition improves hemodynamic responses to hypoxia and exercise in older adults, and that this may be related to elevated circulating ATP.Support or Funding InformationHL119337, F31HL126377This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Analysis of distribution and drug resistance of pathogens of burn patients during 9 years

Objective: To investigate distribution and drug resistance of pathogens of burn patients. Methods: A total of 3 357 strains were cultured and isolated from 25 286 specimens of wounds excretion, deep venous catheters, venous blood, stool, mid-stream urine, sputum, puncture fluid, and throat swab of 11 510 burn patients hospitalized in our burn wards from January 2007 to December 2015. After being identified by API bacteria identification panels and automatically bacteria identification equipment, drug-resistances of Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae to 28 common antibiotics were tested by drug sensitivity test with K-B paper disk diffusion method. The WHONET 5.6 software was used to analyze constituent ratio of gram-negative bacteria and gram-positive bacteria in each year, distribution of pathogens in each year, and drug resistance of the above-mentioned 4 pathogens in 9 years to 28 common antibiotics. Data were analyzed by the linear model curve fitting. Results: (1) From 2007 to 2015, constituent ratios of gram-negative bacteria were respectively 41.22% (101/245), 41.88% (165/394), 45.92% (169/368), 42.54% (208/489), 52.35% (267/510), 56.89% (194/341), 58.99% (210/356), 56.95% (172/302), and 50.28% (177/352), with significantly increasing trend (R(2)=0.625, P<0.05); constituent ratios of gram-positive bacteria were respectively 58.78% (144/245), 58.12% (229/394), 54.08% (199/368), 57.46% (281/489), 47.65% (243/510), 43.11% (147/341), 41.01% (146/356), 43.05% (130/302), 49.72% (175/352), with significantly decreasing trend (R(2)=0.625, P<0.05). In 9 years, constituent ratio of Staphylococcus aureus ranked the first in all bacteria, and constituent ratios of Pseudomonas aeruginosa and Klebsiella pneumoniae were with significantly increasing trend (R(2)=0.811, 0.778, P<0.01). (2) In 9 years, drug-resistant rates of Staphylococcus aureus to gentamycin and rifampicin were with significantly decreasing trend (R(2)=0.727, 0.766, P<0.01); drug-resistant rates of Staphylococcus aureus to phosphonomycin were always in lower levels of 4.6% to 19.5%. In 9 years, drug-resistant rates of Pseudomonas aeruginosa to ceftazidime and ciprofloxacin had no significant change in trend (R(2)=0.023, <0.001, P>0.05), while drug-resistant rates of Pseudomonas aeruginosa to other 10 common antibiotics were with significantly increasing trend (R(2)=0.764, 0.793, 0.785, 0.768, 0.752, 0.749, 0.789, 0.786, 0.706, 0.629, P<0.01). In 9 years, drug-resistant rate of Acinetobacter baumannii to ampicillin/sulbactam was with significantly decreasing trend (R(2)=0.652, P<0.01), and drug-resistant rate of Acinetobacter baumannii to amikacin was with significantly increasing trend ( R(2)=0.531, P<0.05). In 9 years, drug-resistant rates of Klebsiella pneumoniae to piperacillin, ampicillin/sulbactam, cefuroxime, ceftazidime, cefotaxime, cefepime, imipenem, meropenem, amikacin, and gentamicin were with obviously increasing trend (R(2)=0.481, 0.672, 0.694, 0.532, 0.810, 0.641, 0.809, 0.709, 0.579, 0.810, P<0.05 or P<0.01). Conclusions: Constituent ratios of gram-positive bacteria of Pseudomonas aeruginosa and Klebsiella pneumoniae of burn patients hospitalized in our burn wards from 2007 to 2015 were significantly increased, while constituent ratios of Staphylococcus aureus of those children always ranked the first. Drug-resistence of bacteria of those children in our burn wards was serious. Drug-resistant rate of Staphylococcus aureus only to phosphonomycin was always in lower level. Drug-resistant rates of Pseudomonas aeruginosa to 10 common antibiotics except ceftazidime and ciprofloxacin were significantly increased. Drug-resistant rate of Acinetobacter baumannii only to ampicillin/sulbactam was significantly decreased. Drug-resistant rates of Klebsiella pneumoniae to most common antibiotics were significantly increased.