Catheter Replacement Research Articles

A Phase I Trial of Neoadjuvant Stereotactic Body Radiotherapy (SBRT) Prior to Radical Prostatectomy (RP) in Locally Advanced Prostate Cancer

A Phase I Trial of Neoadjuvant Stereotactic Body Radiotherapy (SBRT) Prior to Radical Prostatectomy (RP) in Locally Advanced Prostate Cancer

Changes in Anesthesia Can Reduce Periprocedural Urinary Retention After EVAR

Enhanced recovery after surgery (ERAS) programs provide a streamlined approach for expedient postoperative care of high-volume procedures. Endovascular aortic repair (EVAR) has become standard treatment for abdominal aortic aneurysms and implementation of an early recovery program is warranted. Postoperative urinary retention (POUR) remains a problem lending to longer hospital stays and patient discomfort. We aim to demonstrate the utility of monitored anesthetic care (MAC) plus local anesthesia as a modality to minimize urinary retention following EVAR. Single-center retrospective review from January 2017 to March 2020 of all patients undergoing standard elective EVAR under general anesthesia or MAC anesthesia. Local anesthetic at vessel access sites was used in all patients under MAC. Ruptured pathology and female sex were excluded from analysis. Patient characteristics, operative details, prostate measurements, and outcomes were abstracted from the electronic medical record. Urinary retention was defined as any requirement of straight catheterization, urinary catheter replacement, or discharge with urinary catheter. Chi square tests and logistic regression were used to determine predictors associated with POUR and increased hospital length of stay. Among 138 patients who underwent EVAR, eight (5.8%) were excluded due to ruptured pathology. Of the cohort, 113 (86.9%) were male with mean age of 73 years. Excluding female patients, 63 (55.8%) male patients underwent general anesthesia and 50 (44.3%) underwent MAC. Male patients under general anesthesia were more likely to have intra-operative urinary catheter placement when compared to MAC (82.5% vs. 36%, respectively; P < 0.001). POUR was identified in 17 patients (13.1%) of the entire study population with 15 events (88.2%) occurring in males. Excluding patients who were admitted to the ICU, twenty-two (19.5%) male patients stayed past postoperative day (POD) one, of which those who developed POUR were more likely to experience compared to those without POUR (45.6% vs. 9.7%, respectively; P=0.001). On multivariable analysis, male patients who received MAC had a lower risk of developing POUR (OR 0.09, 95% CI 0.02-0.50). POUR was not associated with elective urinary catheter placement nor with pre-existing conditions such as diabetes, urinary retention, benign prostatic hypertrophy (BPH), or use of BPH medications. Additionally, neither prostate size nor volume was associated with developing POUR among male patients. MAC plus local anesthesia is associated with decreased rates of POUR after elective EVAR in male patients. ERAS pathways during elective EVAR interventions should implement MAC plus local anesthesia as an acceptable anesthetic option, where appropriate, in order to reduce urinary retention rates and subsequently decrease hospital length of stay in this patient cohort.

Routine Replacement versus Clinically Indicated Replacement of Peripheral Venous Catheters through Assessment of Incidences and Grades of Phlebitis in Patients with IV Cannula at a Tertiary Care Hospital, Mumbai

Background: The current study assesses the incidences and grades of phlebitis among patients with IV cannula to determine the association of grades of phlebitis. The purpose of the study was to study the feasibility of Routine replacement versus Clinically indicated replacement of peripheral venous catheters. The study observes the incidences of removing peripheral intravenous catheters when clinically indicated compared with removing and re‐siting the catheter routinely.&#x0D; Methods: An observational study was conducted in the tertiary care private hospital of Mumbai, India. The study was conducted over 5 weeks from May -June 2020. Purposive sampling was considered during the collection of data. The sample size of the study was 117 patients admitted having peripheral venous catheters. The standard visual infusion phlebitis (VIP) score was used as a tool for data collection. Descriptive analysis was done. &#x0D; Results: Out of 117 patients (VIP score 0 -56, Score 1- 49, Score -12 no cases with score 3, 4, and 5). Routine replacement of IV cannula after every 5 days is judiciously followed, 45 healthy lines were replaced at score 0; which is the major concern (Rs. 633/- the total cost of replacing 1 PVC line). &#x0D; Conclusion: Following the routine practice of IV cannula replacement based on VIP score to avoid phlebitis is equally good but simultaneously clinically indicated replacement of IV cannula is advisable to make it cost-effective and reduced number of a prick to the patients; this will help to improve patient satisfaction.

SC108 - Predictors of early catheter replacement after HoLEP: results from a high-volume laser center

SC108 - Predictors of early catheter replacement after HoLEP: results from a high-volume laser center

Ultrasound-Guided Percutaneous Drainage of Abdominal Collections—An Analysis over 5 Years

Introduction. Ultrasound-guided (US-guided) percutaneous drainage (PD) of abdominal collections represents the first-choice alternative to surgical intervention. The aim of our study was to assess the efficacy and safety of PD of visceral and non-visceral abdominal collections by reviewing our personal experience over a period of 5 years. Material and methods. The present study included 66 patients who underwent PD under ultrasound guidance. We analyzed clinical variables (collection size, catheter diameter, collection type, microbiological analysis, antibiotic regimens) along with the outcomes of the procedure. Results. Visceral collections were predominant, encompassing 38 hepatic abscesses and 1 splenic hematoma. Microbiological analysis showed that the majority (54%) were monomicrobial. The most encountered pathogens were Klebsiella pneumoniae and Escherichia coli. Technical success was achieved in all cases and clinical success was observed in 84.6% of the cases. No immediate procedural complications were detected. There were 6 patients who needed reinterventions, either by catheter replacement or by surgical treatment. The mortality rate was 4.5%, due to patients’ poor overall status and oncological comorbidities. Conclusions. Percutaneous drainage under ultrasound guidance is a safe and effective procedure in the management of abdominal collections.

Comparison of Routine Replacement With Clinically Indicated Replacement of Peripheral Intravenous Catheters

Peripheral intravenous catheters (PVCs) are the most frequently used indwelling devices in hospitals worldwide. Peripheral intravenous catheter bloodstream infections (PVC-BSIs) are rare, but severe and preventable, adverse events. To investigate the incidence of PVC-BSIs after changing the policy of routine PVC replacement every 96 hours to clinically indicated replacement. This institution-wide, observational cohort study evaluated all patients hospitalized at a large university-affiliated hospital with 10 sites in Western Switzerland with a PVC insertion between January 1, 2016, and February 29, 2020. Peripheral intravenous catheters were routinely replaced every 96 hours until March 31, 2018 (baseline period). Between April 1, 2018, and October 15, 2019, PVCs were replaced if clinically indicated (intervention period). From October 16, 2019, PVCs were again routinely replaced every 96 hours (reversion period). The PVC-BSI rates and PVC-BSI incidence rate ratios (IRRs) during each period. A total of 412 631 PVCs with documented catheter duration were included (164 331 patients; median [interquartile range] patient age, 51 [33-72] years; 88 928 [54.1%] female): 241 432 PVCs at baseline, 130 779 at intervention, and 40 420 at reversion. Eleven PVC-BSIs were observed during the baseline period, 46 during the intervention, and 4 during the reversion period. Although the monthly number of PVC-days remained stable during all study periods, the number of monthly inserted PVCs decreased during the intervention period. The number of PVCs still in place more than 4 or more than 7 days was higher during the intervention period compared with the baseline and reversion periods. A significantly increased IRR of PVC-BSIs was observed for the intervention period (IRR, 7.20; 95% CI, 3.65-14.22; P < .001) compared with baseline, whereas during the reversion period there was no significant increase (IRR, 1.35; 95% CI, 0.30 6.17; P = .69). The results of this cohort study using a large, prospective surveillance database suggest that replacement of PVCs only when clinically indicated may be associated with an increased risk of PVC-BSI compared with routine replacement. Even if PVC-associated BSI is a rare event, the use of PVCs in most patients makes this outcome relevant.

Initial Clinical Experience with a Symmetric Tip Tunneled Hemodialysis Catheter Without Side Holes.

The purpose of this article is to assess the performance and safety of a novel, symmetric, side-hole–free tunneled cuffed catheter hypothesized to sustain adequate flow without the need for side holes. Between November 2016 and January 2019, Pristine hemodialysis catheters were placed de novo in 45 end-stage renal disease patients (27 males and 18 females) at a single investigational site. Forty-one catheters were placed in the right and four in the left internal jugular vein. There were no incidents of insertion failure. Patients had dialysis three times per week and were followed at four investigational sites. Nominal catheter flows, incidence of poor flow, and catheter-related infections were recorded at each dialysis session and analyzed. The average follow-up time was 161.69 days for a total of 7116 catheter days. Nine patients died from reasons unrelated to the catheter and one patient switched to fistula. Four patients had poor flows necessitating catheter replacement. Four patients had catheter-related bloodstream infections which resolved with antibiotics. These equate to 0.56 events per 1000 catheter days. Catheter survival was 100%, 97.6%, and 89.7% at 30, 90, and 180 days, respectively. The initial clinical assessment of the symmetric Pristine hemodialysis catheter featuring a Y-tip devoid of side holes revealed good catheter performance and survival and a low complication rate.

Improved Patient Safety and Quality Outcomes With Amiodarone Infusions.

Amiodarone is a common intravenous medication and a known irritant to the vessel wall when administered peripherally. Nurses identified an increase in phlebitis associated with peripheral amiodarone leading to multiple catheter replacements and interruptions in drug therapy. Central venous access is recommended by the manufacturer but not practical for a short-term infusion based on the risk to the patient, time, and cost. A 4-phased approach was used to identify a more suitable peripheral intravenous catheter. A collaborative effort between bedside nurses and the vascular access team evolved to look at alternative products for peripheral intravenous catheters. The extended dwell peripheral catheter decreased phlebitis from 54% to 5%. It also decreased interruptions in drug therapy and improved patient comfort and satisfaction. A practice change was implemented utilizing extended dwell peripheral catheters for intravenous amiodarone and disseminated to other units.

P121. Utilizing double machine learning to discern risk factors for preoperative depression among anterior cervical discectomy and fusion (ACDF) patients

<h3>BACKGROUND CONTEXT</h3> The Patient Health Questionnaire-9 (PHQ-9) is a common instrument for assessing depressive symptoms and has been validated in numerous patient populations. Cross-fitting or double machine learning (ML) is a method of variable selection that has gained increased attention for its potential to identify coefficients of interest. Among patients undergoing anterior cervical discectomy and fusion (ACDF), a better understanding of the factors associated with greater depressive symptoms may assist in identifying patients who could benefit the most from management of depressive symptoms prior to surgical intervention. <h3>PURPOSE</h3> In this study, we use ML to assess and identify the most significant risk factors associated with moderately severe depressive symptoms (PHQ-9≥15) among patients undergoing ACDF. <h3>STUDY DESIGN/SETTING</h3> Retrospective Cohort. <h3>PATIENT SAMPLE</h3> A total of 147 patients who underwent single or multilevel ACDF procedures. <h3>OUTCOME MEASURES</h3> Demographic and baseline characteristics, pain levels (Visual Analog Scale [VAS] arm and neck pain). <h3>METHODS</h3> We conducted a retrospective review of patients undergoing single or multilevel ACDF between 2016 and 2019. We excluded patients if they underwent surgery due to infection, metastasis or trauma. Demographic and baseline characteristics were recorded. We recorded degenerative spinal diagnoses and symptoms and postoperative complications. We assessed demographics, baseline characteristics, pain levels (Visual Analog Scale [VAS] arm and neck pain) and spine pathologies with a bivariate analysis to explore how much they elevated the risk of preoperative depression. We used a cross-fit partialling-out least absolute shrinkage and selection operator (LASSO) logistic regression to estimate odds ratios (OR), confidence intervals, and to adequately control for and select significant covariates contributing to increased levels of preoperative depression. <h3>RESULTS</h3> There were 147 patients who underwent single or multilevel ACDF procedures. The cohort was 59% female, 43% had an elevated body mass index (BMI) and 16% had a smoking history. Other comorbidities included hypertension (29.3%), diabetes (12.2%), arm pain (49.7%) and neck pain (48.3%). The rate of moderately severe baseline depressive symptoms (PHQ-9≥15) was 16.3%. The most common preoperative spinal pathologies and symptoms included myeloradiculopathy (90.5%), herniated nucleus pulposus (82.3%), weakness (8.8%) and radiculopathy (6.8%). The only postoperative complication was urinary retention (1.4%). Both urinary retention cases required brief catheter replacement and were resolved prior to discharge. On bivariate analysis, significant baseline characteristics associated with higher levels of preoperative depression (PHQ-9 ≥ 15) included: BMI ≥30 kg/m2 (OR = 2.2, p = 0.040), WC insurance (OR = 2.2, p = 0.035), VAS arm pain ≥7 (OR = 2.5, p = 0.032), and VAS neck pain ≥7 (OR = 4.1, p = 0.003). Our cross-fit partialing-out LASSO regression revealed VAS neck pain ≥7 (OR = 6.8, p = 0.002) and BMI ≥30 kg/m2 (OR = 3.0, p = 0.034) as potentially significant risk factors for preoperative depression severity. <h3>CONCLUSIONS</h3> Our study utilized DML to identify risk factors associated with elevated levels of preoperative depression among patients undergoing single or multilevel ACDFs. The most significant risk factors associated with moderately severe depression included increased neck pain and BMI. Further investigations are needed to identify potential ACDF outcomes and complications that are most associated with increased levels of preoperative depression influences. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Peripherally Inserted Central Catheter Placement in a Cardiology Ward: A Focus Group Study of Nurses' Perspectives.

Intravenous therapy administration through peripheral venous catheters is one of the most common nursing procedures performed in clinical contexts. However, peripherally inserted central catheters (PICC) remain insufficiently used by nurses and can be considered a potential alternative for patients who need aggressive intravenous therapy and/or therapy for extended periods. The purpose of this study was to understand nurses’ perspectives about PICC implementation in their clinical practice. As part of an action-research project, three focus groups were developed in June 2019 with nineteen nurses of a cardiology ward from a Portuguese tertiary hospital. From the content analysis, two main categories emerged: ‘nursing practices’ and ‘patients’. Nurses considered PICC beneficial for their clinical practice because it facilitates maintenance care and catheter replacement rates. Moreover, nurses suggested that, since there is a need for specific skills, the constitution of vascular access teams, as recommended by international guidelines, could be an advantage. Regarding patient benefits, nurses highlighted a decrease in the number of venipunctures and also of patient discomfort, which was associated with the number of peripheral venous catheters. Infection prevention was also indicated. As an emerging medical device used among clinicians, peripherally inserted central catheters seem to be essential to clinical practice.

Risk of hospitalization, technique failure, and death with increased training duration in 3-days-a-week home hemodialysis.

Quality training is a core component of successful home hemodialysis (HHD) and training duration varies significantly between dialysis centers as well as at the patient level. This study aimed to assess the adverse outcomes associated with HHD training duration. All HHD patients successfully trained in a single dialysis center between January 2005 and July 2017 were included. A multivariable multiple-events (Andersen-Gill) survival model was built to evaluate the association between training time and main adverse events, including hospitalizations, technique failure, and death on HHD. Potential confounding factors were defined a priori (age, diabetes, coronary artery disease, and year of training start). Adjusted risk of vascular interventions (arteriovenous fistula angioplasties and central venous catheter replacements) was assessed as the secondary outcome in a negative binomial regression. Forty-eight patients were included in the study. Median HHD training duration was 86 (67-108) days, using a thrice weekly training schedule. Over a follow-up median time of 2.0 (0.7-3.3) years, three patients died while on HHD, 10 had a definitive transfer to HD, and 18 experienced a least 1 hospitalization (38 hospitalizations in total). Training duration was associated with a higher risk of hospitalization, technique failure, and death in unadjusted (hazard ratio [HR] 1.16 per month, 95% confidence interval [CI] 1.08-1.24) and adjusted multiple events model (HR 1.21, 95% CI 1.04-1.43). Risk of vascular access intervention was also significantly higher with increased training time (adjusted incidence rate ratio 1.31, 95% CI 1.03-1.64, per training month). In this single-center observational study, HHD training duration was associated with a higher risk of adverse events including, death, technique failure, hospitalizations, and vascular access intervention. Enhanced clinical follow-up and home support should be offered to these more vulnerable patients to mitigate this heightened risk.

The impact of anatomical variables on haemodialysis tunnelled catheter replacement without fluoroscopy.

Tunnelled haemodialysis (HD) catheters can be used instantly, but there are several anatomical variables that could impact it survival. This study aimed to examine the impact of different novel anatomic variables, with catheter replacement. In a single-centre a prospective cohort in chronic kidney disease G5 patients were conducted. The primary outcome was to determine the factors associated with catheter replacement during the first 6-month of follow-up. All procedures were performed without fluoroscopy. Three anatomic regions for catheter tip position were established: considered as superior vena cava (SVC), cavo-atrial junction (CAJ) and mid-to deep atrium (MDA). Many other anatomical variables were measured. Catheter-related bloodstream infection was also included. Between January 2019 and January 2020 a total of 75 patients with tunnelled catheter insertion were analysed. Catheter replacement at 6-month occur in 10 (13.3%) patients. By multivariate analysis, the incorrect catheter tip position (SVC) (OR 1.23, 95% CI 1.07-1.42, p <.004), the presence of extrasystoles during the procedure (OR 0.88, 95% CI 0.78-0.98, p=.03), incorrect catheter tug (OR 1.31, 95% CI 1.10-1.55, p=.003), incorrect catheter top position (kinking; OR 1.40, 95% CI 1.04-1.88, p=.02) and catheter-related bloodstream infection (OR 2.60, 95% CI 2.09-3.25, p <.001) were the only variables associated with catheter replacement at 6-month follow-up. The risk of catheter replacement at 6-month follow-up could be attenuated by avoiding incorrect catheter tug and top position, and by placing the vascular catheter tip in the CAJ and MDA.

Omentectomy reduces the need for peritoneal dialysis catheter revision in children: a study from the Pediatric Nephrology Research Consortium.

There are no multi-center studies examining omentectomy and peritoneal dialysis (PD) catheter revision in the pediatric dialysis population. We performed a retrospective study at eight centers within the Pediatric Nephrology Research Consortium (PNRC). Data review included all incident tunneled PD catheters placed between 1/1/2011 and 12/31/2016 in pediatric stage 5 chronic kidney disease (CKD 5) patients. The primary outcome was the need for catheter revision and/or replacement. Multivariable logistic regression was performed to evaluate predictors for catheter revision/replacement. Data from 184 children (62.5% male; median age 7.4 years) were analyzed. Omentectomy was completed in 63.6% (n = 117). Revision/replacement occurred in 34.2% (n = 63); median time to revision/replacement was 38.5 days after insertion. PD catheter revision/replacement catheter occurred in 23.9% who underwent omentectomy versus 52.2% without omentectomy (p = 0.0005). Children ≥ 6 years at the time of catheter insertion experienced fewer revisions/replacements (18.2% age ≥ 6 vs. 56.5% age < 6 years, p <0.001). After adjusting for covariates, omentectomy reduced the need for revision by 63%; revision was 3.66 times more likely in those < 6 years of age. This multi-center study demonstrates that omentectomy at the time of PD catheter insertion in pediatric patients is strongly associated with reduced likelihood of PD catheter revision. Omentectomy should be considered at the time of PD catheter insertion, especially in young children who are at high risk for PD catheter malfunction. A higher resolution version of the Graphical abstract is available as Supplementary information.

Simple periprocedural precautions to reduce Doppler microembolic signals during AF ablation

BackgroundDoppler microembolic signals (MES) occur during atrial fibrillation ablation despite of permanent flushed transseptal sheaths, frequent controls of periprocedural coagulation status and the use of irrigated ablation cathetersPurposeTo investigate the number and type of MES depending on the procedure time, prespecified procedure steps, the activated clotting time (ACT) during the ablation procedure and the catheter contact force.MethodsIn a prospective trial, 53 consecutive atrial fibrillation patients underwent pulmonary vein isolation by super-irrigated “point-by-point” ablation. All patients underwent a periinterventional, continuous transcranial Doppler examination (TCD) of the bilateral middle cerebral arteries during the complete ablation procedure.ResultsAn average of 686±226 microembolic signals were detected by permanent transcranial Doppler. Thereby, 569±208 signals were differentiated as gaseous and 117±31 as solid MES. The number of MES with regard to defined procedure steps were as follows: gaseous: [transseptal puncture, 26 ± 28; sheath flushing, 24±12; catheter change, 21±11; angiography, 101±28; mapping, 9±9; ablation, 439±192; protamine administration, 0±0]; solid: [transseptal puncture, 8±8; sheath flushing, 9±5; catheter replacement, 6±6; angiography, not measurable; mapping, 2±5; ablation, 41±22; protamine administration, 0±0]. Significantly less MES occurred with shorter procedure time, higher ACT and the use of tissue contact force monitoring.ConclusionThe current study demonstrates that during atrial fibrillation ablation using irrigated, “point-by-point” RF ablation, masses of microembolic signals are detected in transcranial ultrasound especially in the period of RF current application. The number of MES depends on the total procedure time and the reached ACT during ablation. The use of contact force monitoring might reduce MES during RF ablation.

MO868CLINICAL OUTCOMES FOR INTRAVENOUS DRUG USERS REQUIRING HAEMODIALYSIS

Abstract Background and Aims Intravenous drug users (IVDU) face significant challenges when requiring long-term therapies such as dialysis and pose management dilemma to clinicians. Many patients present late, complicated by erratic lifestyles and complex mental health needs, often requiring urgent renal replacement therapy (RRT). Decisions regarding modality can be difficult due to the lack of evidence for outcomes in this cohort. We investigated the clinical outcomes of patients with history of IVDU in our service who presented with ESRD. Method A single-centre retrospective analysis of ESRD patients with a background of IVDU. Incidence of hospital and ICU admission, length of stay and frequency of culture positive sepsis following the initiation of RRT were investigated. Primary outcome was days admitted versus days spent in the community, frequency of life-threatening sepsis and tunnelled catheter replacement. Data was collected from the date of first RRT (earliest April 2015 and latest November 2019) to last follow-up in September 2020 or patient death. An admission was included when the patient was admitted for at least an overnight stay in hospital. Admission days calculated do not include attendance for outpatient haemodialysis. Bacteraemia’s were included when a report confirming a positive culture associated with clinical features of infection; paired samples were counted as a single episode. Results Six patients initiated RRT during the study period and included four males and two females. Mean age of 46.6 years (32-54 years). Cause of ESRD was Amyloid AA in 5) and IgA nephropathy in 1). Mean follow-up was 677 days till censor (range 313 to 932 days). There was an average of nine inpatient admissions (range 3 to 17) averaging 280 inpatient days (range 29 to 637 days) across the cohort. At last follow-up, three patients died with an average time to death of 833 days from initiation of RRT (range 664 to 932 days). Four patients required at least one admission to the Intensive Care Unit (ITU) with an average length of stay of 10.3 days (range 1 to 47 days). All patients experienced at least two episodes of culture positive sepsis with a total of 72 bacteraemia’s across the cohort (range 2 to 41). Four patients required tunnelled catheter replacement ranging from 2 to 7 catheters. Results are summarised in Table 1. Conclusion IVDU patients represent a challenging patient population to manage with limited options available for RRT. This study highlights these difficulties particularly with the use of tunnelled catheters for haemodialysis. Our results indicate RRT in IVDUs is associated with frequent and prolonged hospital stays with multiple bacteraemia’s, ICU admissions and significant mortality. Clinicians are faced with a significant ethical dilemma as tunnelled catheters represent both a lifeline for continued survival and a perfect access to recreational drugs. If patients are to be offered haemodialysis via tunnelled access, more intensive and earlier multidisciplinary planning and counselling needs to be employed to ensure patients are aware of the significance of the associated risks. Psychological therapy and social care input would be essential to help reduce morbidity and mortality.

Locked Away-Prophylaxis and Management of Catheter Related Thrombosis in Hemodialysis.

Reliable vascular access is necessary for effective hemodialysis. Guidelines recommend chronic hemodialysis via an arteriovenous fistula (AVF), however, in a significant number of patients, permanent central venous catheters (CVCs) are used. The use of a tunneled catheter is acceptable if the estimated dialysis time is less than a year or it is not possible to create an AVF. The main complications associated with CVC include thrombosis and catheter-related bloodstream infections (CRBSIs), which may result in loss of vascular access. The common practice is to use locking solutions to maintain catheter patency and minimize the risk of CRBSI. This paperwork summarizes information on currently available locking solutions for dialysis catheters along with their effectiveness in preventing thrombotic and infectious complications and describes methods of dealing with catheter dysfunction. The PubMed database was systematically searched for articles about locking solutions used in permanent CVCs in hemodialysis patients. Additional studies were identified by searching bibliographies and international guidelines. Articles on end-stage kidney disease patients dialyzed through a permanent CVC were included. Information from each primary study was extracted using pre-determined criteria including thrombotic and infectious complications of CVC use, focusing on permanent CVC if sufficient data were available. Of the currently available substances, it seems that citrate at a concentration of 4% has the best cost-effectiveness and safety profile, which is reflected in the international guidelines. Recent studies suggest the advantage of 2+1 protocols, i.e., taurolidine-based solutions with addition of urokinase once a week, although it needs to be confirmed by further research. Regardless of the type of locking solution, if prophylaxis with a thrombolytic agent is chosen, it should be started from the very beginning to reduce the risk of thrombotic complications. In case of CVC dysfunction, irrespective of the thrombolysis attempt, catheter replacement should be planned as soon as possible.

Neuraxial labor analgesia failure rates in women with a body mass index ≥50 kg/m2: a single-center retrospective study

BackgroundThe failure rate of neuraxial labor analgesia has not been investigated in super-obese women (body mass index ≥50 kg/m2). MethodsWe performed a retrospective study of neuraxial labor analgesia in super-obese women (January 2012 to August 2019). The primary outcome was the failure rate of the first neuraxial catheter. Secondary outcomes were failure rates by neuraxial technique, at cesarean delivery, and rate of catheter replacement. ResultsNeuraxial labor analgesia was used by 233 super-obese women: 153 epidural catheters placed using a combined spinal-epidural (CSE) or dural puncture epidural techniques with visualization of cerebrospinal fluid; 63 placed without dural puncture (including procedures without attempted dural puncture or attempted CSE or dural puncture epidural); and 17 intrathecal catheters (seven intentional). Thirty-two of 233 neuraxial catheters failed (13.7%, 95% Confidence Interval [CI] 9.9 to 18.7%). Epidural catheters placed using CSE or dural puncture epidural had a lower failure rate than those placed without dural puncture (9.2%, 95% CI 5.5% to 14.7%) vs 28.6% (95% CI 18.9% to 40.7%; P<0.001). Catheter migration was documented for 29.4% (95% CI 16.8 to 46.2%) of catheters that failed. ConclusionsEpidural catheters placed using CSE or dural puncture epidural techniques were more reliable than those placed without dural puncture in super-obese parturients. It is unclear whether the result was driven by grouping procedures without attempted dural puncture with those in which dural puncture was attempted but cerebrospinal fluid was not obtained. Catheter migration was a major source of failure.

Impact of central venous catheter repair in pediatric intestinal failure.

Patients with intestinal failure (IF) require long-term parenteral nutrition through central venous catheters (CVCs). When damaged, catheter replacement or repair is considered. Limited literature exists on repair outcomes in this population. We aimed to assess the impact of repair on durability of exiting CVCs and infection rates. This was a retrospective cohort study of pediatric IF patients with tunneled silicone CVCs over 10 years. Outcomes were evaluated by assessing CVC longevity, repair success, replacement, and postrepair infection rates. One hundred thirty-eight repairs and 45 replacements were conducted in 37 patients with repair and replacement rates of 4.7 and 1.5 per 1000 catheter days, respectively. Twenty patients (54%) required ≥1 repair. For CVCs requiring repair, median CVC durability without and with repairs were at 123 and 391 days, respectively (P < .0001). Overall repair success rate was 96% with significantly lower success in the emergency department at 81% (P = .007). The 7-day postrepair infection rate was 2.2% without specific risk factors identified. Most repairs (76%) were performed by the Pediatric Gastroenterology division. Variability in practice was noted among services, including frequency of periprocedural antibiotic use and performance of temporary repairs before permanent repairs. A gradual increase in CVC repair rate was noted over time. Our study showed that CVC repair is effective in prolonging CVC durability in pediatric IF patients without increasing infection rates. Incorporating a temporary repair as a step before permanent repair may offer a route to address potential intraluminal thrombosis before permanent repair.

CLINICAL ANALYSIS OF 95 CASES OF PERCUTANEOUS CYSTOSTOMY

(Introduction) Percutaneous cystostomy is a standard urological procedure; however, very few reports have focused on the many cases of this procedure performed in Japan. We analyzed the background of the procedure and its approach as well as the incidence of its complications at our institution. (Material and methods) We examined 95 patients who underwent percutaneous cystostomy between April 2010 and March 2019. A comparative analysis was conducted for each type of procedure performed. Furthermore, cases that experienced accidental catheter extraction before the first catheter replacement were analyzed, and the three patient groups were compared based on the type of procedure performed and cases that needed another operation. (Result) The indications for cystostomy were urethral stricture (56.3%), neuropathic bladder (13.5%), and prostatic hyperplasia (11.5%). The complications included hemorrhage, peritoneal injury, urinary tract infection, and catheter damage caused by a puncture needle. The overall complication rate was 10.5%. Based on type of the procedure performed, the incidence of hemorrhage was found to be as high as 25% in patients who underwent the procedure using a cannula puncture needle. Accidental catheter extraction before the first catheter replacement occurred most frequently in patients treated with Seldinger technique (17.0%). The rate of complications including accidental catheter extraction ranged from 25.0% to 25.4% among the three groups. (Conclusion) We prefer the Seldinger technique for the first placement of the cystostomy catheter because of its low rate of hemorrhage, but a cannula puncture needle may also be used by using exploratory puncture if vascular damage and accidental catheter extraction are avoided.

Transrenal Hemodialysis Catheter Insertion and Replacement in Patients with Upper Extremity Central Venous Access Exhaustion.

Patients undergoing long-term hemodialysis may suffer upper extremity central venous access failure and require an alternative route. This study aimed to evaluate the safety and efficacy of transrenal hemodialysis catheter insertion/replacement in patients with upper extremity central venous access failure. A multicenter retrospective cohort study was made of transrenal hemodialysis catheter insertion/replacement performed between 2014 and 2020. The history of renal replacement therapy and central venous catheters and the technical details of transrenal hemodialysis catheter insertion/replacement, patency, removal and complications were obtained for all patients. Six insertion and four replacement procedures involving transrenal hemodialysis catheters were evaluated in six patients (M:F = 3:3; median age, 49.5years). Percutaneous transrenal (right:left = 1:5) hemodialysis catheter insertion was technically successful without complication in all six patients. In two patients, the tract was not lost because the safety guidewire was still in place, so no second puncture was required. The mean procedure time was 33.0 ± 9.2min. The mean primary patency duration was 107.3 ± 70.9days. During the mean follow-up duration of 141.2 ± 137.1days, four hemodialysis catheter replacement procedures were successfully performed for catheter malfunction (n = 2) and dislodgement (n = 2). Catheter removal was successfully performed in four patients after confirming normal coagulation, followed by subsequent renal replacement therapy. Percutaneous insertion/replacement of transrenal hemodialysis catheters is feasible, safe, and effective when upper extremity central venous access is exhausted, and the catheters can be maintained for a reasonable period of time. Level 4, Case Series.