Catheter Malposition Research Articles

Placement of subcutaneous ureteral bypasses without fluoroscopic guidance in cats with ureteral obstruction: 19 cases (2014-2016).

Objectives The purpose of this study was to describe the perioperative and postoperative complications as well as short-term and long-term outcomes in cats with ureteral obstructions treated by placement of a subcutaneous ureteral bypass (SUB) device without imaging control. The second objective of this study was to compare cats treated by SUB device with cats treated by traditional surgical intervention. Methods Data were obtained retrospectively from the medical records (2014-2016) of cats that underwent SUB placement (SUB cats) and cats that underwent traditional ureteral surgery (C cats). Results Nineteen SUB devices were placed without fluoroscopic, radiographic or ultrasonographic guidance in 13 cats. Fifteen traditional interventions (ureterotomy and neoureterocystostomy) were performed in 11 cats. Successful placement of the SUB device was achieved in all cats with only one major intraoperative complication (kinking of the kidney catheter) and one minor intraoperative complication (misplacement of the kidney catheter). Eleven SUB cats recovered from the surgical procedure; two SUB cats and three C cats died during the anaesthesia recovery period. Postoperative SUB complications included anaemia (n = 2), urinary tract infection (UTI) (n = 4), non-infectious cystitis (n = 5) and SUB device obstruction (n = 1). Postoperative traditional surgery complications included anaemia (n = 7), UTIs (n = 6), non-infectious cystitis (n = 1), re-obstruction (n = 4) and ureteral stricture (n = 1). Median postoperative duration of hospitalisation (3 days) was significantly shorter for SUB cats than for C cats ( P = 0.013). Ten SUB cats (76.9%) and four C cats (40%) were still alive at a median follow-up of 225 days and 260 days, respectively. Owners were completely (90%) or mostly (10%) satisfied with the SUB device placement. Conclusions and relevance SUB device placement appears to be an effective and safe option for treating ureteral obstruction in cats, and this study has shown that fluoroscopic guidance is not essential in all cases.

Application and comparison of different implanted ports in malignant tumor patients.

BackgroundThe current study aims to compare the application and convenience of the upper arm port with the other two methods of implanted ports in the jugular vein and the subclavian vein in patients with gastrointestinal cancers.MethodsCurrently, the standard of practice is placement of central venous access via an internal jugular vein approach. Perioperative time, postoperative complications, and postoperative comfort level in patients receiving an implanted venous port in the upper arm were retrospectively compared to those in the jugular vein and the subclavian vein from April 2013 to November 2014.ResultsThree hundred thirty-four patients are recruited for this analysis, consisting of 107 in the upper arm vein group, 70 in the jugular vein group, and 167 in the subclavian vein group. The occurrence of catheter misplacement in the upper arm vein is higher than that in the other two groups (13.1 vs. 2.9 vs. 5.4 %, respectively, P = 0.02), while the other complications in the perioperative period were not significantly different. The occurrence of transfusion obstacle of the upper arm vein group is significantly lower than that of the jugular and subclavian groups (0.9 vs. 7.1 vs. 7.2 %, P = 0.01). The occurrence of thrombus is also lower than that of other two groups (0.9 vs. 4.3 vs. 3.6 %, P = 0.03). Regarding the postoperative comfort, the influences of appearance (0 vs. 7.1 vs. 2.9 %, P = 0.006) and sleep (0.9 vs. 4.2 vs. 10.7 %, P = 0.003) are significantly better than those of the jugular and subclavian vein groups.ConclusionsCompared to the jugular and the subclavian vein groups, the implanted venous port in the upper arm vein has fewer complications and more convenience and comfort, and might be a superior novel choice for patients requiring long-term chemotherapy or parenteral nutrition.

Influence of Mechanical Ventilation on the Incidence of Pneumothorax During Infraclavicular Subclavian Vein Catheterization: A Prospective Randomized Noninferiority Trial.

It remains unclear whether we have to interrupt mechanical ventilation during infraclavicular subclavian venous catheterization. In practice, the clinicians' choice about lung deflation depends on their own discretion. The purpose of this study was to assess the influence of mechanical ventilation on the incidence of pneumothorax during infraclavicular subclavian venous catheterization. A total of 332 patients, who needed subclavian venous catheterization, were randomly assigned to 1 of the 2 groups: catheterizations were performed with the patients' lungs under mechanical ventilation (ventilation group, n = 165) or without mechanical ventilation (deflation group, n = 167). The incidences of pneumothorax and other complications such as arterial puncture, hemothorax, or catheter misplacements and the success rate of catheterization were compared. The incidences of pneumothorax were 0% (0/165) in the ventilation group and 0.6% (1/167) in the deflation group. The incidence of pneumothorax in the deflation group was 0.6% higher than that in the ventilation group and the 2-sided 90% confidence interval for the difference was (-1.29% to 3.44%). Because the lower bound for the 2-sided 90% confidence interval, -1.29%, was higher than the predefined noninferiority margin of -3%, the inferiority of the ventilation group over the deflation group was rejected at the .05 level of significance. Other complication rates and success rates of catheterization were comparable between 2 groups. The oxygen saturation dropped below 95% in 9 patients in the deflation group, while none in the ventilation group (P = .007). The success and complication rates were similar regardless of mechanical ventilation. During infraclavicular subclavian venous catheterization, interruption of mechanical ventilation does not seem to be necessary for the prevention of pneumothorax.

Routine Chest Radiography Is Not Necessary After Ultrasound-Guided Right Internal Jugular Vein Catheterization.

Central venous catheter placement is a common procedure performed on critically ill patients. Routine postprocedure chest radiographs are considered standard practice. We hypothesize that the rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low. Retrospective chart review. Adult ICUs, emergency departments, and general practice units at an academic tertiary care hospital system. All 1,322 ultrasound-guided right internal jugular vein central venous catheter attempts at an academic tertiary care hospital system over a 1-year period. None. Data from standardized procedure notes and postprocedure chest radiographs were extracted and individually reviewed to verify the presence of pneumothorax or misplacement, and any intervention performed for either complication. The overall success rate of ultrasound-guided right internal jugular vein central venous catheter placement was 96.9% with an average of 1.3 attempts. There was only one pneumothorax (0.1% [95% CI, 0-0.4%]), and the rate of catheter misplacement requiring repositioning or replacement was 1.0% (95% CI, 0.6-1.7%). There were no arterial placements found on chest radiographs. Multivariate regression analysis showed no correlation between high-risk patient characteristics and composite complication rate. In a large teaching hospital system, the overall rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low. Routine chest radiograph after this common procedure is an unnecessary use of resources and may delay resuscitation of critically ill patients.

Identical wave forms of vena cava and pulmonary artery during pulmonary artery catheter insertion due to kinking: a case report of a rare complication.

BackgroundWe experienced a rare malposition of a pulmonary artery catheter due to kinking in a 63-year-old male who was scheduled for an off-pump coronary artery by-pass graft.FindingsGiven the difficulty to obtain stable pulmonary artery waveform, we discovered that the two waveforms of the distal and proximal ports of the pulmonary artery catheter were completely identical. Subsequent fluoroscopy revealed that because the catheter had formed a kink around the apex of the right ventricle, the distal port faced the proximal port of the catheter.Conclusions We recommend that both ports of the pulmonary artery catheter need to be monitored simultaneously in case neither portable fluoroscopy nor transesophageal echo is available.

Laparoscopic insertion of the peritoneal catheter in ventriculoperitoneal shunting. Review of 405 consecutive cases

BackgroundBased upon our excellent previous experience with 151 adult patients and 39 children whom had the peritoneal catheter in ventriculoperitoneal shunting placed laparoscopically, we continued following this technique as a first-line-procedure in ventriculoperitoneal shunting. Now we analyzed our experience with additional 405 cases for a better comprehension of the complications, advantages and disadvantages of this procedure on this high number of patients. A strict interdisciplinary setting with the maximum of medical intraoperative competence was our goal and therefore better results. Material and methodsN = 405 patients with intraperitoneal shunt insertion from the years 2006–2013 (Follow-up period ranges from 2 to 9 years with a 5,9-year mean follow-up period) were retrospectively analyzed with a special focus on the possible peritoneal catheter complications after laparoscopical shunt insertion. In our department all the peritoneal catheters in ventriculoperitoneal shunting are inserted laparoscopically, when there is no contraindication for this technique. ResultsWe had 0% peritoneal catheter misplacement rate with help of the laparoscopic technique. In two cases (0.49%) injury of the small bowel could be repaired immediately with no further action required. In two cases umbilical hernias have been accidently discovered and the repair of the hernias took place in the same surgical session. As this technique helps us to control the shunt position intraperitoneally by direct laparoscopic vision, the patients spared an extra radiation exposure, to control the position of the peritoneal catheter. A diagnostic laparoscopy is also possible if needed. The time of the operation is shortened in comparison with the needed time, which is mentioned in literature, for the open laparotomy and of course the needed anesthesia and its possible risks and complications decreased. ConclusionNo revision surgeries were required because of any misplacement of the peritoneal catheter, no additional technique related risks compared to the open surgical technique, no abdominal x-rays were needed, the operation time is shortened and the dose of anesthesia needed is decreased and of course its possible side effects' rate is also decreased. Another great benefit of this technique is the possibility of accidental diagnosis of intra-abdominal pathologies. Also, if a surgical treatment of this accidentally discovered intra-abdominal pathologies is needed, it can take place in the same surgical session. No prolonged surgery time as the laparoscopic technique is much easier, controllable and fast.

Misplacement of central venous catheter into the left internal mammary vein

SummaryCentral venous catheter insertion is a commonly performed procedure in anaesthesia and critical care in order to assist fluid management and to allow administration of intravenous medications. Central venous catheter misplacement can occur, even in expert hands, despite the widespread use of ultrasound guidance. In this case report, we describe central venous catheter misplacement into the left internal mammary vein and subsequent patient management.

Complication avoidance in laser interstitial thermal therapy: lessons learned.

OBJECTIVE Complications of laser interstitial thermal therapy (LITT) are underreported. The authors discuss how they have modified their technique in the context of technical and treatment-related adverse events. METHODS The Medtronic Visualase system was used in 49 procedures in 46 patients. Between 1 and 3 cooling catheters/laser fiber assemblies were placed, for a total of 62 implanted devices. Devices were placed using frameless stereotaxy (n = 3), frameless stereotaxy with intraoperative MRI (iMRI) (n = 9), iMRI under direct vision (n = 2), MRI alone (n = 1), or frame-based (n = 47) techniques. LITT was performed while monitoring MRI thermometry. Indications included brain tumors (n = 12), radiation necrosis (n = 2), filum terminale ependymoma (n = 1), mesial temporal lobe epilepsy (n = 21), corpus callosotomy for bifrontal epilepsy (n = 3), cavernoma (n = 1), and hypothalamic hamartomas (n = 6). RESULTS Some form of adverse event occurred in 11 (22.4%) of 49 procedures. These included 4 catheter malpositions, 3 intracranial hemorrhages, 3 cases of neurological deficit related to thermal injury, and 1 technical malfunction resulting in an aborted procedure. Of these, direct thermal injury was the only cause of prolonged neurological morbidity and occurred in 3 of 49 procedures. Use of frameless stereotaxy and increased numbers of devices were associated with significantly increased complication rates (p < 0.05). A number of procedural modifications were made to avoid complications, including the use of 1) frame-based catheter placement, a 1.8-mm alignment rod to create a track and titanium skull anchors for long trajectories to improve accuracy; 2) a narrow-gauge instrument for dural puncture and coregistration of contrast MRI with CT angiography to reduce intracranial hemorrhage; 3) general endotracheal anesthesia for posterior-placed skull anchors to reduce the likelihood of damage to the cooling catheter; 4) use of as few probes as possible to reduce complications overall; and 5) dose modification of thermal treatment and use of short (3-mm) diffusing tips to limit treatment when structures to be spared do not have intervening CSF spaces to act as heat sinks. CONCLUSIONS Laser ablation treatment may be used for a variety of neurosurgical procedures for patients with tumors and epilepsy. While catheter placement and thermal treatment may be associated with a range of suboptimal operative and postoperative courses, permanent neurological morbidity is less common. The authors' institutional experience illustrates a number of measures that may be taken to improve outcomes using this important new tool in the neurosurgical arsenal.

An unusual malposition of central venous catheter in critically ill patient. Could it be identified during catheterization? The potential role of point-of-care ultrasonography

Malpositioning of central venous catheter is not uncommon and can be associated with complications. We report a case where central venous catheter inserted through right internal jugular approach under real time ultrasonographic guidance was malpositioned with its tip in left brachio-cephalic vein. Chest radiograph for detection of catheter malpositioning is associated with time delay and radiation exposure. Point-of-care ultrasonography can be a valuable bedside tool to identify catheter malpositioning during catheter insertion, thus facilitating immediate catheter repositioning and early use of central venous catheter.Bangladesh Crit Care J March 2016; 4 (1): 44-45

F.07 Reducing ventricular shunt malfunction in the adult patient

Background: Treatment of adult patients with hydrocephalus is often undertaken with a ventriculoperitoneal shunt (VPS). Failure rates have been reported as high as 50% in the first year. Methods: A Quality Improvement (QI) model was used to evaluate and modify VPS-insertion techniques to improve outcome. Malfunction was defined as a change in neurological shunt-related function with correlated diagnostic imaging studies. Prospectively collected data from 2012-2015 was reviewed. Results: 146 patients underwent a new VPS insertion. Diagnoses were: normal pressure hydrocephalus 101 patients, acquired hydrocephalus 28 patients and chronic-congenital hydrocephalus 17 patients. 103 patients had traditional insertion of a ventricular catheter using surface landmarks with 2 catheter misplacements requiring surgery. Image guidance with electromagnetic tracking was instituted with 0 catheter misplacements in 43 consecutive patients. 121 patients had traditional minilaparotomy/trocar placement of the peritoneal catheter with 59/121 (49%) experiencing shunt malfunction and 35/59 (59%) experiencing a second malfunction requiring surgery. Laparoscopic insertion of the peritoneal catheter was instituted in 25 consecutive patients with 3 (12%) distal obstructions. Laparoscopy was also used in 13 patients undergoing VPS revision with 2 (15%) experiencing subsequent malfunction. Conclusions: Changes to standard VPS surgical treatment including the addition of image-guidance and laparoscopic surgical techniques were associated with a significant decrease in shunt malfunction requiring surgery.

Ultrasound-Guided Placement of Central Venous Port Systems via the Right Internal Jugular Vein: Are Chest X-Ray and/or Fluoroscopy Needed to Confirm the Correct Placement of the Device?

Percutaneous central venous port (CVP) placement using ultrasound-guidance (USG) via right internal jugular vein is described as a safe and effective procedure. The aim of this study is to determine whether intraoperative fluoroscopy (IF) and/or postoperative chest X-ray (CXR) are required to confirm the correct position of the catheter. Between January 2012 and December 2014, 302 adult patients underwent elective CVP system placement under USG. The standard venous access site was the right internal jugular vein. The length of catheter was calculated based on the height of the patient. IF was always performed to confirm US findings. 176 patients were men and 126 were women and average height was 176.2cm (range 154-193cm). The average length of the catheter was 16.4cm (range 14-18). Catheter malposition and pneumothorax were observed in 4 (1.3%) and 3 (1%) patients, respectively. IF confirmed the correct position of the catheter in all cases. Catheter misplacement (4 cases) was previously identified and corrected on USG. Our rates of pneumothorax are in accordance with those of the literature (0.5-3%). Ultrasonography has resulted in improved safety and effectiveness of port system implantation. The routine use of CXR and IF should be considered unnecessary.

Outcome assessment of renal replacement therapy in neonates

BackgroundRecent advances in renal replacement therapy (RRT) have brought about a proliferation of dialysis in neonates (<30 d). This study aimed to assess morbidity and mortality after RRT initiation in this population. MethodsRetrospective chart review of all patients between 2006 and 2014 requiring RRT initiated in the first 30 d of life was performed. ResultsA total of 49 patients were identified, of which 39 were boys and 10 were girls. Thirty-two patients (65%) had end-stage renal disease, 11 (22%) had errors of metabolism, and six (12%) required RRT for other pathologies. Median age and weight at RRT onset were 6 (4-14) d and 3.1 (2.7-4.0) kg, respectively. A total of 201 surgeries were performed. Excluding catheter revisions, 83 new hemodialysis (HD) and 28 new peritoneal dialysis lines were placed, with maximum of six HD and four peritoneal catheters placed in single patient. Catheter-associated morbidities occurred in 100% of patients. Most common complications for HD included circuit clotting (87%), bleeding (68%), and bacteremia (50%). Peritoneal dialysis complications included peritonitis (83%), malpositioned catheters (72%), and leaks (55%). Overall mortality was 65.3%, with 56% of all deaths occurring within first month of life and 94% occurring within first year. Among long-term survivors (median follow-up of 5.3 y), 44% were severely and 22% moderately developmentally delayed. ConclusionsAlthough RRT is becoming more technically feasible for neonates with renal and metabolic diseases, it remains associated with significant morbidity and mortality. Pediatric surgeons must be aware of the challenges, taking them into account when considering the care of these critically ill children.

Introduction of a new laparoscopic trocar for insertion of peritoneal dialysis catheters and making a proper rectus sheath tunneling.

Using a proper laparoscopic trocar for making a downward rectus sheet tunneling (RSHT) during the implementation of peritoneal dialysis (PD) catheters leads to a longer survival of catheter and less catheter dysfunction. As no specific laparoscopic trocar has been invented for insertion of PD catheters, we designed a new trocar. In this article, we describe specifications of our new invented trocar for the first time. We will describe our experience with it in our patients as well. The new stainless steel trocar includes a cannula and a mandarin. The cannula consists of a tube pipe and head. The tube pipe is so long that is proper for rectus sheet tunneling, and its internal diameter is fitted for easy passage of the catheter with its cuffs. The head consists of two steel parts holding a unidirectional plastic valve preventing backflow of the air. The mandarin section includes a sharp shaft and a metal cap. The distal end of the mandarin is an atraumatic conical tip which was designed to make a safe RSHT. A total of 30 PD catheters were successfully implanted through 30 laparoscopic procedures in 12 males and 18 females (mean age 48.16±14.18years). All catheters were successfully inserted without any intraoperative complication. Exit-site infection, peri-catheter leakage, and outflow failure were found in two, one, and one patient, respectively. We did not find any inflow failure, catheter malpositioning, migration, or kinking. No other complication was observed during the 1-year follow-up period. The new designed PD trocar is a proper port for laparoscopic implantation of the peritoneal dialysis catheter. It is a safe and easy handle trocar that helps surgeons to make an appropriate rectus sheath tunneling with minimal complications.

Percutaneous cannulation of central veins in neonates: Its safety and feasibility: Audit of 75 neonatal insertions

Introduction: Central venous catheters (CVC) have become an integral part in the care of children in intensive care settings. However, their use in neonates is limited due to inherent difficulties in insertion and associated complications. Objective: We present our experience in the use of CVC by percutaneous cannulation in neonates. Materials and Methods: A total of 75 cases of neonatal percutaneous central venous cannulation inserted over a period of 6-month from March 2014 to August 2014. Data regarding age, indication for central line insertion, site of insertion, complications related to central line insertion, duration of catheter days, werecollected. Results: Of the 75 neonates, 49 were male and 26 were female. Age group ranged from 14 to 30 days with a median of 21 days. Weight ranged from 750 g to 3.5 kg with an average of 1.9 kg. The internal jugular vein was accessed in 45 (60%), followed by femoral 26 (34.6%) and subclavian in 4 (5.3%) cases. Successful percutaneous cannulation was achieved in all and the median catheter days were 12 days. The longest catheter patency was 46 days in one neonate. The most common indication for placement was failure of peripheral venous access (78%). The main complications encountered were catheter displacement (12%) and catheter malposition (9.3%). Catheter induced sepsis was seen in 7 (9.3%) neonates. Conclusion: Percutaneous cannulation of central veins in neonates is feasible, and safe, with acceptable morbidity. Ultrasound guided central line insertions is becoming the gold standard in neonates, as the entire vascular anatomy is delineated and variations in anatomy clearly identified; hence avoiding multiple attempts and complications.Contrast injected X-rays confirmation even when the catheter is radio-opaque is effective in accurate tip identification and helps in preventing tip related complications.

Santral Venöz Kateterizasyon Sonrası Sol Brakiyosefalik Ven Perforasyonu

Central venous hemodialysis catheter applications are still the most common route for acute hemodialysis and some complications may be seen at the time of insertion or later and some of these may be fatal. Catheter malpositions and great vessel perforations have an important place among these complications. Vessel perforations may be fatal if not diagnosed in the early period and treated appropriately and may share the same symptomatology with other acute dialysis complications such as anaphylactic reactions, air embolism and acute coronary syndromes. We discuss chest pain occurring at the onset of dialysis in a patient with left brachiocephalic vein perforation and its similarities with the symptoms of other dialysis complications. keY wordS: Brachiocephalic vein, Hemodialysis, Perforation

Outcomes after peritoneal dialysis catheter placement

BackgroundThe purpose of this study was to review surgical outcomes after elective placement of peritoneal dialysis (PD) catheters in children with end-stage renal disease. MethodsChildren with PD catheters placed between February 2002 and July 2014 were retrospectively reviewed. Outcomes were catheter life, late (>30days post-op) complications (catheter malfunction, catheter malposition, infection), and re-operation rates. Comparison groups included laparoscopic versus open placement, age<2, and weight<10kg. Univariate and multivariate analysis were performed. ResultsOne hundred sixteen patients had 173 catheters placed (122 open, 51 laparoscopic) with an average patient age of 9.7±6.3years. Mean catheter life was similar in the laparoscopic and open groups (581±539days versus 574±487days, p=0.938). The late complication rate was higher for open procedures (57% versus 37%, p=0.013). Children age<2 or weight<10kg had higher re-operation rates (64% versus 42%, p=0.014 and 73% versus 40%, p=0.001, respectively). Adjusted for age and weight, open technique remained a risk factor for late complications (OR 2.44, 95% CI 1.20–4.95) but not re-operation. DiscussionLaparoscopic placement appears to reduce the rate of late complications in children who require PD dialysis catheters. Children <2years age or <10kg remain at risk for complications regardless of technique.

Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of placement

BackgroundSuboptimal position of tunneled central venous catheters (Broviacs) decreases long-term catheter longevity, incurring morbidity and cost. We postulated that catheter malposition is related to patient's age, technique used, and initial catheter tip location (CTL). MethodsWe performed a retrospective review with 1-year follow-up of Broviacs placed in patients at our children's hospital from 3/2010 to 10/2013. We defined malposition as a noncentral CTL that required replacement, excluding catheters physically dislodged. We used logistic regression to determine whether age, technique and CTL predicted malposition with p-value<0.05 deemed significant. We analyzed line longevity for different insertion techniques by survival analysis. ResultsOverall, 404 upper body Broviacs were placed in 282 children (median age=1.4years [IQR:0.45–5.35]). Thirty-six (8.9%) were replaced for malposition, at median of 84.5days [IQR:36–159]. We found that older children were less likely to develop malposition (OR=0.91,p=0.002). Adjusting for patient age and placement technique, catheters placed ≥1.5 vertebral bodies below the carina were less likely to be malpositioned (OR=0.37,p=0.015). Cox-regression shows the lateral technique to have the lowest rate of malposition within 90days (HR=0.30,p=0.03). ConclusionOlder patients and lines placed 1.5 vertebral bodies below the carina are less likely to become malpositioned. Using the lateral approach for insertion improves catheter longevity.

Malposition of Central Venous Catheter: Presentation and Management.

Malposition of Central Venous Catheter: Presentation and Management.

The Insertion and Management of External Ventricular Drains: An Evidence-Based Consensus Statement : A Statement for Healthcare Professionals from the Neurocritical Care Society.

External ventricular drains (EVDs) are commonly placed to monitor intracranial pressure and manage acute hydrocephalus in patients with a variety of intracranial pathologies. The indications for EVD insertion and their efficacy in the management of these various conditions have been previously addressed in guidelines published by the Brain Trauma Foundation, American Heart Association and combined committees of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. While it is well recognized that placement of an EVD may be a lifesaving intervention, the benefits can be offset by procedural and catheter-related complications, such as hemorrhage along the catheter tract, catheter malposition, and CSF infection. Despite their widespread use, there are a lack of high-quality data regarding the best methods for placement and management of EVDs to minimize these risks. Existing recommendations are frequently based on observational data from a single center and may be biased to the authors' view. To address the need for a comprehensive set of evidence-based guidelines for EVD management, the Neurocritical Care Society organized a committee of experts in the fields of neurosurgery, neurology, neuroinfectious disease, critical care, pharmacotherapy, and nursing. The Committee generated clinical questions relevant to EVD placement and management. They developed recommendations based on a thorough literature review using the Grading of Recommendations Assessment, Development, and Evaluation system, with emphasis placed not only on the quality of the evidence, but also on the balance of benefits versus risks, patient values and preferences, and resource considerations.

A Novel Technique for Correcting Peritoneal Dialysis Catheter Malposition and Blockage.

Methods To investigate the safety and clinical significance of the method described in this study, we focused on 16 peritoneal dialysis patients with peritoneal dialysis (PD) catheter malposition and blockage in whom nonsurgical reposition was ineffective, who received a local incision about 5 cm below hypogastrium PD catheter insertions under local anesthesia. Tissues were separated layer by layer, 1-cm incisions were performed on the peritoneum vertically and conventionally, and then the PD catheters were pulled. Adherent mesentery was separated and the PD catheters were freed and removed sufficiently. PD catheters were introduced into the Dow cavity using large introducing forceps, were loop-ligated and fixed using 3# silk thread, and then the ligation line was sutured to the peritoneum. The tissues were managed layer by layer and the skin was sutured. All patients were followed up for half a year. Results Sixteen cases of refractory PD catheter malposition and blockage were managed successfully, with an operative incision of 3 cm and an operation time of 40±13 minutes. The localized anesthesia was well tolerated, and there were five cases in which lidocaine at 5 mg was added during the operation; postoperative pain was slight and only three patients used analgesics at night. All patients were treated with coagulation hemostasis, and there was no transfusion. No malposition, leakage or blockage was found at follow-up at more than six months. Conclusion It is safe, simple, inexpensive and associated with fewer complications to correct refractory PD catheter malposition and blockage by loop ligature and fixation through a minilaparotomy of inserted hypogastrium PD catheters promptly.