Midline catheters - what could be done better? A retrospective evaluation of clinical registry

Introduction. Midline catheters (MCs) are an option for vascular access alongside the commonly used short peripheral intravenous catheters, centrally and peripherally inserted central catheters.Aim. The aim of this study was to evaluate the solution implemented during the COVID-19 pandemic in a centre where MC access had not been used before.Material and method. It was an observational retrospective evaluation of the 98 medical registries of adult patients.Results. The mean time from hospital admission to midline catheter insertion was 15 days. The most common indications for the catheter implementation were: difficult intravenous access (83%) and expected time hospital stay >6 days (17%). The mean dwell time of the catheters was 9 days. The most common reasons for removal were: the end of intravenous therapy (44%) and catheter blockages (36%).Conclusions. A high level of prematurely removed catheters was observed, despite the existence of a hospital protocol. The high percentage of MCs removed before the end of intravenous therapy may be indicative of the poor quality of care and the need for continuous education of medical staff. The results obtained should be confi rmed in a prospective study planned on their basis in order to identify interventions which are necessary to improve the quality of vascular access care.

Risk factors influence the arterial line patency in ICU-bound patients during COVID-19 pandemic: An observational cohort study

Background There were increased claims of thrombotic events in ICU-bound patients with COVID-19. We designed this observational study to examine implementation of systemic anti-coagulation on arterial catheter patency and its failure and to identify risk factors for arterial catheter failure. Methods A total of 245 COVID-19 subjects were included in this observational study, 48 patients in the non-systemic, (Non-SA), (Prophylactic) anticoagulation cohort, and 197 patients in the systemic (SA), (Therapeutic) anticoagulation group. The first arterial line inserted on ICU admission for every patient was monitored regarding its duration of the patency, number and location of consecutive arterial lines inserted during stay in ICU. Demographics of patients, ICU parameters and risk factors for arterial line failure were followed and analyzed. Results The percentage of arterial line failure was significantly higher in Non-SA group, 45.8% when compared to SA group, 25.9%, P = 0.007. The patients with arterial line failure exhibited higher D-dimer, co-morbidities, diabetic patients, received aspirin and mortality than the patent group, respectively, p = 0.002, p = 0.002, p < 0.0001, p < 0.0001, and p < 0.0001. This group also received higher sedation and prone position on mechanical ventilation and higher vasopressors, respectively, p = 0.034, p < 0.0001, p < 0.0001, and p < 0.0001 when compared to patent group. They had prolonged length of stay in ICU and hospital, respectively, p = 0.001 and p = 0.042. The cumulative incidence of index arterial line failure (Log-rank test 6.95, P = 0.008) with overall percentage was significantly lower in SA group (25.9%) compared to non-SA group (45.8%), respectively, P = 0.007. On Cox-proportional hazard multivariate regression analysis, independent predictors of arterial line failure increased platelets level (HR 1.00, 95% CI 1.00-1.01, P = 0.001), use of ultrasound use in arterial line insertion (HR 4.68, 95% CI 1.75-12.56, P = 0.002), and prone position in ICU (HR 1.94, 95% CI 1.09-3.42, P = 0.023). Conclusion We observed three independent predictors of arterial line failure including platelets level and ultrasound use during arterial catheter insertion and prone position in ICU. Systemic anticoagulation was associated with more patency of arterial catheter than prophylactic therapy group.

Adaptation of midline and mini-midline catheters for patients with COVID-19

Objective: to analyse the time of permanence andmain causes for removal of midline (20 cm) and mini-midline (10 cm) catheters in hospitalized patients, and to study the differences in patients with COVID-19. Method: a descriptive, cross-sectional, retrospective study conducted with data from clinical records in the Hospital Universitario Vall d´Hebron (Barcelona, Spain). The study includedcatheters insertedby the Infusion andVascular Access Nursing (IVAN) Team in patients hospitalized during 2020. Results: the study included 357 catheters in 305 patients (28.9% with COVID-19). The latter presented a higher rate of obesity (21.6% vs. 9.2%;p= 0.003). The median duration of catheters inserted was 11-12 days, without any difference by type of catheter or having COVID-19 (p= 0.88). The main cause for removal in both groups was the end of the treatment, and it was higher in patients without COVID-19 (65.7% vs. 53.1%;p= 0.031), followedby exitus in patients withCOVID-19 (22.9% vs. 8.9%;p= 0.001), and catheter occlusion in the rest (17.3% vs. 8.33%;p= 0.035). There were n= 4 cases of catheter infection and n= 31 suspected cases, without difference by diagnosis or type of catheter. There was no variation in the cause for removal according to the venous access selected. Conclusions: there are no differences in terms of duration of catheters according to their length, vein of insertion or COVID-19 diagnosis. Ultrasound-guided venipuncture, sterile technique and selection of type of catheter by a member of the IVAN team seem to reduce the complications associated. © 2022 DAE Editorial, Grupo Paradigma. All rights reserved.

Safety of Extending Implanted Vascular Access Device Maintenance Flush Frequency

The study reviewed current standards of care for IVAD flush maintenance frequency, examined the characteristics of blood from IVADs by aspirating and observing contents prior to flushing when maintenance care is delayed beyond four weeks, and identified whether more research is required to determine optimal IVAD maintenance flush frequency methods: KEYWORDS port maintenance;guideline variations;flushing;oncology;standards of care;biofilm more than two billion intravascular devices, which are widely used in critical patients and patients with cancer, are inserted globally each year (He et al., 2019). Project Procedures A literature review included a search from January 2016 through April 2022 and encompassed current INS, Oncology Nursing Society, National Comprehensive Cancer Network, and Centers for Disease Control and Prevention guidelines and recommendations for practice, and manufacturer guidance. [...]once the Huber needle was inserted, aspiration was attempted to observe for a brisk blood return.

Case-control study on the association between nosocomial bloodstream infections and glucocorticoids, tocilizumab, systemic antibiotics, mechanical ventilation and length of hospital stay in COVID-19 hospitalised patients

Background and ImportanceHospitalised patients with COVID-19 are often exposed to immunosuppressive and anti-inflammatory drugs in addition to systemic antibiotic treatments. Nosocomial bloodstream infections (nBSI) have been associated with the need for mechanical ventilation or venous catheter insertion. However, there is current controversy regarding the influence of immunosuppressive, anti-inflammatory and antimicrobial drugs on nBSI occurrence.Aim and ObjectivesAssess the association between glucocorticoids, tocilizumab, systemic antibiotics and nonpharmacologic health interventions and the occurrence of nBSI in hospitalised patients with COVID-19.Material and MethodsCase–control study including cases of nBSI episodes in adult inpatients with SARS-CoV-2 pneumonia over a one-year period and controls without nBSI. Sociodemographic and clinical data were collected during hospitalisation. Bivariable analysis was performed. Numerical variables were compared using the Student's t-test or the Mann-Whitney test and categorical variables using the χ2 or Fisher's exact test. Variables with a p-value<0.1 in bivariable analysis were included in a multivariable logistic regression model to assess the factors independently associated with nBSI occurrence (p-value<0.05).Results50 cases with COVID-19 and 50 controls were included. Mean age was 63.0 ± 12.4(66% men, 2.3 ± 2.1 mean Charlson index and comparable between groups). nBSI episodes showed significantly higher length of hospital stay(LOS) (OR 1.173, 95% CI: 1.144-1.257, p<0.001), surgeries (OR 10.80, 95% CI: 1.310-88.5, p=0.008), need for mechanical ventilation(OR 8.10, 95% CI: 3.31-19.8, p<0.001) antibiotic and glucocorticoids therapy days (OR 1.166, 95% CI: 1.112-1.122, p=0.017 and OR 3.20, 95% CI: 1.325-7.287, p=0.010, respectively), and tocilizumab use (OR 9.33, 95% CI: 1.115-77.125, p=0.017). Non-significant higher number of chronic renal failure cases were present among nBSI episodes (p=0.1). Multivariate regression analyses showed mechanical ventilation (aOR 4.892, 95% CI: 1.206-19.845, p=0.026) and LOS (aOR 1.231, 95% CI: 1.104-1.371, p<0.001) as independent risk factors for nBSI when corrected for the presence of surgeries, central venous catheter, tocilizumab, chronic renal failure and the days of antibiotic and glucocorticoid treatment.Conclusion and RelevanceThis study found nBSI independently associated with mechanical ventilation and LOS and did not find an association between nBSI and the pharmacological interventions assessed. However, given the bivariate association between these pharmacological interventions and nBSI, and previous inconclusive literature on the effects of these treatments on bacterial and fungal infections occurrence, further investigation with a larger sample is required.1ReferenceCodina-Jiménez C., et al. Risk factors for nosocomial bloodstream infections in COVID-19 affected patients: protocol for a case-control study. Eur J Hosp Pharm.2022Conflict of InterestNo conflict of interest

NURSE MANAGER CNS PARTNERSHIP FOR QUALITY ROUNDING

With the stresses of Covid-19 and challenges with staffing, our oncology medical-surgical unit saw a slip in our nurse sensitive indicator quality metrics. A few interventions were put into place that helped for a short time but didn't take traction. The Nurse Manager (NM) and Clinical Nurse Specialist (CNS) looked for evidence- based ideas to get the quality metrics to below the National Database of Nursing Quality Indicators (NDNQI) benchmark targets. Using the Define, Measure, Analyze, Improve, Control (DMAIC) quality improvement methodology we put into place a plan to do weekly quality improvement rounds. The purpose of the quality rounds by the NM and CNS is to determine if preventative measures are properly in place and to re-enforce education to the patient and family. Follow up can also be provided to the nursing staff about measures not in place or not yet completed. Feedback to the staff can be provided in real time. Each week an appointment is sent so there is dedicated time for the rounds on both the NM and CNS calendar. Determination of which patients to see is based on presence of a central line, foley catheter, Braden score below 18 and being a fall risk. There are several items we are looking for when in the room. For example, when rounding on a patient who is at a risk for falling, we check that the bed alarm is on and plugged in correctly, the floor is free from any tripping hazards, the bedside table with frequently needed items is within arm's reach as is the call light and we re-enforce to call for help before getting out of bed. If we find items not in place, e.g., the bed alarm is not turned on, we turn the alarm on and follow up with the nursing staff. Currently, the quality rounds have been in place for almost two months. Since that time there have been two falls, no pressure injuries, no central line associated blood stream infections (CLABSI) nor any catheter associated urinary tract infections (CAUTI). We will continue to monitor effectiveness of rounding. Oncology patients are at a higher risk of infection and injury. By hard wiring interventions, we can prevent complications, decrease hospital length of stay and improve quality of life.

S6 Timing of pneumothorax post-CT-guided thoracic biopsy in a tertiary referral centre: implications for the ambulatory pneumothorax pathway

S6 Table 1Study population characteristicsn % Total number of procedures 641 - Male 371 57.9% Female 270 42.1% Median age (years) 71.0 - Lesion site RUL 177 27.61% RML 22 3.43% RLL 109 17.00% LUL 151 23.56% LLL 104 16.22% Anterior mediastinal 29 4.52% Pleural 40 6.24% Chest wall 9 1.40% Median lesion size (mm) 41 - Total pneumothorax incidence 223 34.8% Timing of pneumothorax T = 0 hours 186 83.41% T = 0-2 hours 37 16.59% T = 2 hours - 7 days 0 0.00% Pneumothorax management(% of n=223) Conservative 144 64.57% Aspiration 47 21.08% Chest drain 31 13.90% Pleural vent 1 0.45% Total pneumothorax needing intervention (% of n=223) 79 35.43% Immediate pneumothorax management (% of n=186) Conservative 111 59.68% Aspiration 46 24.73% Chest drain 28 15.05% Pleural vent 1 0.54% Immediate pneumothorax needing intervention (% of n=186) 75 33.63% Delayed pneumothorax management (% of n=37) Conservative 33 89.19% Aspiration 1 2.70% Chest drain 3 8.11% Pleural vent 0 0.00% Delayed pneumothorax needing intervention (% of n=37) 4 10.81% ConclusionsThis study demonstrates that the incidence of delayed-onset pneumothorax requiring intervention is low in a tertiary centre setting. The optimal time for patient observation post-CTGB remains unknown. The authors acknowledge a high incidence of pneumothorax in the study cohort, which they postulate may be due to a higher volume of complex procedures in a tertiary setting, higher sensitivity of CT for reporting trivial post-biopsy pneumothorax, and the diversion of more complex lung cancer patients to the CTGB route during the COVID pandemic to avoid aerosol-generating procedures.ReferenceHeerink WJ, de Bock GH, de Jonge GJ, Groen HJ, Vliegenthart R, Oudkerk M. Complication rates of CT-guided transthoracic lung biopsy: meta-analysis. Eur Radiol 2017;Jan;27(1):138–148.

Antibiotic use during coronavirus disease 2019 intensive care unit shape multidrug resistance bacteriuria: A Swedish longitudinal prospective study.

Objectives: High frequency of antimicrobial prescription and the nature of prolonged illness in COVID-19 increases risk for complicated bacteriuria and antibiotic resistance. We investigated risk factors for bacteriuria in the ICU and the correlation between antibiotic treatment and persistent bacteria. Methods: We conducted a prospective longitudinal study with urine from indwelling catheters of 101 ICU patients from Uppsala University Hospital, Sweden. Samples were screened and isolates confirmed with MALDI-TOF and whole genome sequencing. Isolates were analyzed for AMR using broth microdilution. Clinical data were assessed for correlation with bacteriuria. Results: Length of stay linearly correlated with bacteriuria (R2 = 0.99, p ≤ 0.0001). 90% of patients received antibiotics, primarily the beta-lactams (76%) cefotaxime, piperacillin-tazobactam, and meropenem. We found high prevalence of Enterococcus (42%) being associated with increased cefotaxime prescription. Antibiotic-susceptible E. coli were found to cause bacteriuria despite concurrent antibiotic treatment when found in co-culture with Enterococcus. Conclusion: Longer stays in ICUs increase the risk for bacteriuria in a predictable manner. Likely, high use of cefotaxime drives Enterococcus prevalence, which in turn permit co-colonizing Gram-negative bacteria. Our results suggest biofilms in urinary catheters as a reservoir of pathogenic bacteria with the potential to develop and disseminate AMR.

Device Nurses Can Prevent CLABSIs

The article talks about how the hiring by UConn Health in Fairfeld, Connecticut of two epidemiology nurses has helped in preventing central line-associated bloodstream infection (CLABSI). Topics covered include the daily device rounds performed by the nurses, the critical oversight and infection prevention that they provide, and the easy-to-use antiseptic swab with a shorter scrub and dry time for catheter insertion implemented by the hospital.

Salvage of infected tunneled hemodialysis catheters using 70% ethanol lock solution: A brief report.

Tunneled hemodialysis catheters are the lifeline to patients on maintenance hemodialysis with failed arteriovenous fistulas. However, thrombosis and infection are the main causes of reduced longevity of these accesses. According to IDSA guidelines, catheter-related infection with Pseudomonas and fungi are absolute indications for catheter removal. Considering the cost and difficulties in catheter replacement, for those in whom all accesses are exhausted, retaining the same catheter may be lifesaving. We would like to present two patients in whom, 70% ethanol instillation was used to eradicate infection with these organisms as confirmed by repeat cultures post procedure. Hemodialysis is being successfully continued through the same catheter.

Clinical audit on indications and technique of male urethral catheterization in emergency department of a tertiary care hospital.

Urethral catheterization (UC) is a common procedure done in the Emergency Department of a hospital. The main indications for a UC are relieving acute urinary retention and bladder outlet obstruction. This cross-sectional audit was carried out between July 2019 to February 2020, in the Emergency Department (ED). All male patients aged 18 years and above, in whom UC was performed, were included in the audit. A total of 81 male patients were surveyed. Although, sterilized technique was maintained by using sterile gloves and pyodine but hand hygiene (sterilization or hand wash) was not performed before the procedure 80% of times. CDC hand hygiene guidelines were distributed to promote hand hygiene. What do we already know about this topic ? The Lippincott guidelines are considered gold standard which includes hand hygiene as an important element of urinary catheterization UC. The CDC Center of Disease Control CDC promotes the use of mandatory gloves and generous hand sanitizing before procedures. How does your research contribute to the field For continuous improvement and patient focused practice, we must audit the technique of nursing staff, doctors and health care assistants who are involved in insertion and ordering of catheters to provide quality health care and avoid unnecessary catheterization [1]. The aim of this study was to audit the appropriateness of usage of urinary catheters by the healthcare staff and, their technique of insertion and indications for urinary catheterization. What are your research's implications towards theory, practice, or policy? Hand hygiene is an important element of patient care. If done properly it can prevent several hospital-acquired infections. Heathcare facilities must audit their staff on regular basis and provide refreshers and promote the use of proper hand hygiene before urinary catheterization.

Continuous fractional spinal anesthesia in a patient coming for hepaticojejunostomy with post covid lung

B265 Figure 1ResultsContinuous fractional spinal anesthesia offers the advantage of fractionating the doses of local anesthetic in the subarachnoid space and has lesser effect on respiratory and cardiac physiologyConclusionsContinuous spinal anesthesia (CSA) is a safer alternative technique to general anesthesia in patients with severe cardio - respiratory disease in whom general anesthesia could result in prolonged ICU stay.

For emergency CS, a labour epidural should be removed and a spinal anaesthetic used instead

Planning, Preparation and Pre-emption are three key concepts in the practice of anaesthesia. In obstetric anaesthesia specifically, these three ‘P’s are particularly relevant as parturients are commonly present the Delivery Suite for a period of time prior to requesting or requiring anaesthetic intervention. One frequently encountered example of implementing Planning, Preparation and Pre-emption by the obstetric anaesthesiologist is the recommendation of starting epidural analgesia during labour. Unless contraindicated, this is suggested or advisable in parturients with modified WHO 3 and modified WHO 4 heart disease1, in women with maternal obesity2, in active COVID-19 infection3, in the presence of certain ophthalmic pathologies4, and in laboring women with pre-eclampsia5, among others. This is to ensure labour analgesia and patient comfort;to prevent deterioration of medical conditions due to the added physiological and psychological stresses of labour;to reduce the need for further anaesthetic intervention should anaesthesia be required for a surgical procedure;and to avoid general anaesthesia wherever possible, reducing the incidence of associated complications and protecting healthcare staff from aerosol-generating procedures.The main benefits of having an established Labour Epidural providing good epidural analgesia are: 1) the possibility of its conversion to an epidural anaesthetic in the case of an emergency Caesarean section, 2) the avoidance of disadvantages associated with removing the Epidural and using a Spinal, and 3) other considerations including cost, environmental impact, anaesthetist workload, and patient perspectives.1. Conversion to Epidural Anaesthesia for Emergency Caesarean SectionLumbar epidurals are regarded as the gold standard for labour analgesia6. The Obstetric Anaesthetists’ Association (OAA) in the United Kingdom estimates that only 5% of labour epidurals will not work well enough for a Caesarean section7, should it be required. In an Irish study, the rate of labour epidurals converted to spinal or general anaesthesia for Caesarean section was 9%8, the conversion rate from an Indian study was approximately 4%9, a Maltese study identified a rate of epidural conversion to spinal or general anaesthesia for Caesarean section as 0.85% and 1.5% respectively10, a Chinese publication showed a conversion rate to general anaesthesia of 3%11, while a systematic review in 2022 by authors from the United Kingdom and the United States of America including over 3000 patients showed an overall prevalence of inadequate epidural anaesthesia of around 30%12. It is however worth noting that this systematic review relates to elective caesarean section, and not emergencies, with the possibility that epidural analgesia was not established for a significant period of time prior to the procedure.Naturally, it is important to ensure that the epidural analgesia provided during labour is satisfactory to increase chances of success of epidural anaesthesia for emergency Caesarean section13. A number of risk factors have been identified as being associated with a failure of conversion from epidural analgesia to anaesthesia and recommendations for their mitigation14, in line with the spirit of Planning, Preparation and Pre-emption, have been made. The presence of an obstetric anaesthetist has also been mentioned as a relevant factor in this regard15.Furthermore, the time required for an epidural top up to a level adequate for surgical anaesthesia compares favourably with that required for a spinal, and in some cases, even with that required for a general anaesthetic. A 2018 retrospective cohort study showed that unadjusted median operating room-to-incision intervals were 6 minutes for general anaesthesia, 11 minutes for epidural top-up, and 13 minutes for spinal anaesthesia16. It is important to point out that when relating to clinical significance, general anaesthesia was associated with worse short term neonatal outcomes in this study, and that longer time intervals were not associated with worse neona al outcomes16. A 2007 retrospective audit from Australia showed mean decision-to-delivery times of 17 (±6) minutes for general anaesthesia, 19 (±9) minutes for epidural, and 26 (±9) minutes for spinal17. It has also been reported that established epidural analgesia may mitigate the increased anaesthesia and surgery time required in obese obstetric patients undergoing Caesarean section18.Finally, epidural anaesthesia for emergency Caesarean section has the benefit of being topped up as often as required to prolong the duration of the anaesthetic block. It also allows for manipulation of the time of onset of the anaesthetic, speeding it up by using lignocaine together with adjuvants such as opiates, bicarbonate, or adrenaline;or even providing a gentle onset of neuraxial anaesthetic blockade when required, for example, in patients with severe heart disease. One-shot spinal anaesthesia does not confer these benefits.Therefore, it can be said that in over 90% of cases where a functioning labour epidural analgesia is present, this can be satisfactorily used for emergency Caesarean section anaesthesia in a timely manner. This is very promising data which encourages the anaesthesiologist to utilize epidural top ups, instead of removing the labour epidural and attempting an alternative technique.2. Disadvantages associated with removing the Epidural and using a SpinalThe decision to remove a labour epidural for an emergency Caesarean section and opt for a spinal anaesthetic has its disadvantages. Firstly, as described above, the anaesthesiologist is losing an anaesthetic option which has a high chance of success and is negating some benefits related to Planning, Preparation and Pre-emption in obstetric anaesthesia. Secondly, the patient is being exposed to the potential complications associated with a second procedure, which may not have been justifiably necessary. In this case, there is always the possibility that a spinal anaesthetic is not possible to site due to patient anatomy, difficulty with appropriate positioning in an emergency situation, challenges resulting from the volume already present in the epidural space, and psychological stress due to the urgency felt by the multidisciplinary team, among others. This would result in the anaesthesiologist having to resort to general anaesthesia, which may further expose the patient to complications such as awareness, aspiration, and difficulty with airway manoeuvres.Additionally, there is controversy in the literature regarding the safety of spinal anaesthesia following pre-established epidural analgesia in obstetrics. A number of authors express concerns regarding the risk of high spinal or total spinal with the injection of local anaesthetic and adjuvants into the cerebrospinal fluid once this is already compressed by the contents of the epidural space14,19. This seems to be more of an issue if a recent epidural bolus would have just been administered, as compared to an epidural infusion only19–20. Case reports of these complications have been published21–22.3. Other considerationsWhen considering the choice between topping up a labour epidural or removing it and using a spinal for emergency Caesarean section, one should also factor in the issues of cost, environmental impact, anaesthesiologist workload, and patient perspectives.It can be argued that removing a labour epidural and performing spinal anaesthesia is more costly than topping up the already-present epidural. A new sterile gown and gloves will need to be used by the anaesthesiologist, together with the opening of a new sterile pack for spinal anaesthesia. This will include consumables, such as the spinal needle, the cleaning solution and swabs;as well as the cost of cleaning, decontamination, and sterilization of any reusable items, which involves the cost of additional staff. The repeated use of personal protective equipment, utilization of consumables, and processes associated with cleaning, decontamination, and sterilization also carries an environmental impact. In a world where cost-efficiency is key, and minimization of environmental impact is important, these considerations cannot be ignored.Choosing to remove a labour epidural and use a spinal anaesthetic for an emergency Caesarean section may also have an effect on the anaesthesiologist in terms of stress and workload. Deciding to remove a working epidural analgesia catheter before even giving it a chance to work is eliminating a realistic anaesthetic option for an emergency procedure. This limits the tools available to the anaesthesiologist as it is not usually feasible for an epidural catheter to be re-inserted in an emergency. It also requires the anaesthesiologist to explain this additional procedure to the patient and gain informed consent in a challenging situation. This extra workload i.e., explaining, gaining informed consent, and inserting a spinal anaesthetic, may be stressful for the anaesthesiologist. Also, they are now required to perform a procedure in a time-pressured and high-stakes environment. Performance anxiety may also play a part if the anaesthesiologist is very keen to avoid a general anaesthetic, for example, if they feel the patient’s airway looks particularly difficult or the patient has pre-eclampsia and would therefore be at a higher risk of complications.Patient perspectives should also be considered. The author has found no published literature specifically relating to patient preference regarding epidural or spinal anaesthesia for emergency Caesarean section. However, it is reasonable to think that a patient who has a working labour epidural already has confidence in the technique and as a result, may feel more reassured with epidural anaesthesia for emergency Caesarean section as compared to alternatives.In summary, labour epidurals providing satisfactory analgesia shouldbe considered for a top up to provide epidural anaesthesia for emergency Caesarean sections. In fact, this is one of the main benefits of siting labour epidurals in patients who are at a higher risk for Caesarean section and is a strong feature of obstetric anaesthesia practice using the principles of Planning, Preparation and Pre-emption. In addition, there are disadvantages to the alternative of removing the labour epidural and using a spinal anaesthetic. Furthermore, there are cost, environmental, anaesthesiologist, and patient considerations that may support the choice of epidural anaesthesia over spinal.National Institute for Health and Care Excellence (Great Britain). Intrapartum care for women with existing medical conditions or obstetric complications and their babies. National Institute for Health and Care Excellence (NICE);2019.Denison FC, Aedla NR, Keag O, Hor K, Reynolds RM, Milne A, Diamond A, on behalf of the Royal College of Obstetricians and Gynaecologists. Care of Women with Obesity in Pregnancy. Green-top Guideline No. 72. BJOG 2018Bauer M, Bernstein K, Dinges E, et al. Obstetric anesthesia during the coronavirus disease 2019 pandemic. Anesthesia and Analgesia 2020 Apr 20.Digre KB. Neuro-ophthalmology and pregnancy: what does a neuro-ophthalmologist need to know? Journal of Neuro-Ophthalmology 2011 Dec 1;31(4):381–7.Siddiqui MM, Banayan JM, Hofer JE. Pre-eclampsia through the eyes of the obstetrician and anesthesiologist. International Journal of Obstetric Anesthesia 2019 Nov 1;40:140–8.Kumar, Nishant DA, DNB, MNAMS Epidural Technique in Obstetric Anesthesia, Anesthesia & Analgesia: March 2021 - Volume 132 - Issue 3 - p e40 doi: 10.1213/ANE.0000000000005359Obstetric Anaesthetists’ Association (OAA). Risk of having an epidural or spinal to reduce labour pain. March 2021. Accessible at: https://www.labourpains.com/Epidural-Information-CardSingh V, Lal S, Thomas J, Narayanan N. ESRA19–0621 Incidence of failed epidural anaesthesia for emergency cesarean section and conversion rate to spinal or general anaesthesia.Pandya ST, Mikkilineni J, Madapu M. Conversion of labour epidural analgesia to anaesthesia for emergency caesarean section: A retrospective audit. Journal of Obstetric Anaesthesia and Critical Care 2021 Jan 1;11(1):5.Abela GP, Thor ton B, Cortis PA, Calleja P. Evaluation of the obstetric anaesthesia procedures at mater dei hospital in 2019. Malta Medical Journal 2022 Jan 11;34(1):43–9.Shen C, Chen L, Yue C, Cheng J. Extending epidural analgesia for intrapartum cesarean section following epidural labor analgesia: a retrospective cohort study. The Journal of Maternal-Fetal & Neonatal Medicine 2022 Mar 19;35(6):1127–33.Patel R, Kua J, Sharawi N, et al. Inadequate neuraxial anaesthesia in patients undergoing elective caesarean section: a systematic review. Anaesthesia. 2022.Visser WA, Zwijnenburg RD. Management of neuraxial anaesthesia for intrapartum caesarean delivery based on the quality of epidural labour analgesia: A case series. European Journal of Anaesthesiology;EJA. 2019 Aug 1;36(8):615–7.Desai N, Carvalho B. Conversion of labour epidural analgesia to surgical anaesthesia for emergency intrapartum Caesarean section. BJA education. 2020 Jan;20(1):26.Bjornestad EE, Haney M. An obstetric anaesthetist: A key to successful conversion of epidural analgesia to surgical anaesthesia for caesarean delivery?. Acta Anaesthesiologica Scandinavica. 2020;64(2):142–4.Palmer E, Ciechanowicz S, Reeve A, et al. Operating room-to-incision interval and neonatal outcome in emergency caesarean section: a retrospective 5-year cohort study. Anaesthesia. 2018 Jul;73(7):825–31.Popham P, Buettner A, Mendola M. Anaesthesia for emergency caesarean section, 2000–2004, at the Royal Women’s Hospital, Melbourne. Anaesthesia and intensive care. 2007 Feb;35(1):74–9.Lawrence S, Malacova E, Reutens D, Sturgess DJ. Increased maternal body mass index is associated with prolonged anaesthetic and surgical times for caesarean delivery but is partially offset by clinician seniority and established epidural analgesia. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2021;61(3):394–402.Vaida S, Dalal P, Mets B. Spinal anesthesia for Cesarean delivery following pre-existing epidural labour analgesia. Canadian Journal of Anesthesia/Journal canadien d’anesthésie 2009 Dec;56(12):988–9.Dadarkar P, Philip J, Weidner C, et al. Spinal anesthesia for cesarean section following inadequate labor epidural analgesia: a retrospective audit. International journal of Obstetric Anesthesia. 2004;13(4):239–43.Siddik-Sayyid SM, Gellad PH, Aouad MT. Total spinal block after spinal anesthesia following ongoing epidural analgesia for cesarean delivery. Journal of Anesthesia 2012;26(2):312–3.Gupta A, Enlund G, Bengtsson M, et al. Spinal anaesthesia for caesarean section following epidural analgesia in labour: a relative contraindication. International Journal of Obstetric Anesthesia 1994 jul 1;3(3):153–6.

Intracranial large bore guide catheter placement is associated with excellent reperfusion: a single institution experience

E-240 Table 1Baseline and disease-related characteristics of study population Intracranial group (n=52) Control group (n=40) P value Female 33 (63.5) 21 (52.5) 0.393 Age, average (SD) 67.1 (15.1) 65.8 (16.8) 0.698 Admission NIHSS, average (SD) 16.7 (6.8) 17.5 (7.5) 0.594 Baseline mRS, average (SD) 0.5 (0.7) 0.8 (1.0) 0.094 Occlusion Site ICA 8 (15.4) 11 (27.5) 0.197 M1 34 (67.3) 22 (55.0) 0.390 M2 10 (19.2) 7 (17.5) >0.999 COVID 3 (5.8) 1 (2.5) 0.630 Thrombolytic therapy use 12 (23.1) 8 (20.0) 0.802 Conscious sedation 48 (90.0) 35 (90.6) 0.495 Values are counts (%) unless noted otherwise.ConclusionIntracranial guide catheter positioning was associated with improved final TICI 2C or better reperfusion rate, better first-pass effect, and quicker access to final reperfusion time in patients suffering emergent large vessel occlusion.DisclosuresJ. Milburn: 2;C;Microvention, Imperative Care. 4;C;Optimize Neurovascular. G. Vidal: None. P. Gulotta: None. S. Milburn: None. M. Poongkunran: None. V. Fennell: None.

Angled tip reperfusion catheters are associated with quicker access to final recanalization and reduced utilization of stent retrievers and secondary catheter usage in patients with emergent large vessel occlusion, which may reduce procedure cost

E-217 Table 1Baseline and disease-related characteristics of study population Zoom Reperfusion System (n=60) Control (n=36) P value Female 37 (61.7) 17 (53.1) 0.507 Age, average (SD) 66.2 (15.0) 67.2 (17.4) 0.774 Admission NIHSS, average (SD) 17.0 (6.8) 17.9 (7.8) 0.567 Baseline mRS, average (SD) 0.6 (0.8) 0.7 (0.9) 0.586 Occlusion Site ICA 12 (20.0) 7 (21.9) >0.999 M1 36 (60.0) 20 (62.5) >0.999 M2 12 (20.0) 5 (15.6) 0.780 COVID 4 (6.6) 0 (0.0) 0.294 Thrombolytic therapy use 12 (16.6) 8 (25.0) 0.603 Conscious sedation 54 (90.0) 29 (90.6) >0.999 Values are counts (%) unless noted otherwise.ConclusionThe use of angled tip aspiration catheters for thrombectomy was associated with quicker time to final recanalization, lower use of stent retrievers, and lower use of additional catheter aspiration, with no increase in rates of symptomatic intracranial hemorrhage. This finding likely translates to a reduced thrombectomy procedure cost.DisclosuresJ. Milburn: 2;C;Microvention, Imperative Care. 4;C;Optimize Neurovascular. P. Gulotta: None. V. Fennell: None. M. Poongkunran: None. S. Milburn: None. G. Vidal: None.

Pooled safety data from the risdiplam clinical development programme

Risdiplam (EVRYSDI®) is a centrally and peripherally distributed, oral survival of motor neuron 2 (SMN2) premRNA splicing modifier approved by the EMA and MHRA for the treatment of patients aged ≥2 months, with a clinical diagnosis of Type 1, 2 or 3 spinal muscular atrophy (SMA) or 1–4 copies of SMN2.Safety data were pooled from three studies within the risdiplam clinical development programme:FIREFISH (NCT02913482) assesses safety, tolerability, pharmacokinetics (PK), pharmacodynamics (PD) and efficacy of risdiplam in infants with Type 1 SMASUNFISH (NCT02908685) assesses safety, tolerability, PK, PD and efficacy of risdiplam in patients with Types 2/3 SMAJEWELFISH (NCT03032172) assesses safety, tolerability, PK and PD of risdiplam in patients who previously received RG7800 (RO6885247), nusinersen (SPINRAZA®), olesoxime or onasemnogene abeparvovec (ZOLGENSMA®).Pooled analyses from FIREFISH, SUNFISH and JEWELFISH showed no treatment-related safety findings leading to withdrawal from risdiplam in 465 patients treated for up to 38.9 months (data-cut-offs: 14 November 2019, 15 January 2020 and 31 January 2020, respectively). The differences in adverse event profiles between Type 1 and Types 2/3 SMA populations appeared to be driven by the severity of the underlying disease. Here we will present updated pooled safety analyses for the risdiplam studies.

Detecting and Classifying Misplaced Catheters III Chest X-Rays Based on Efficient net B7

Catheter tip misalignment can lead to complications in patients together with serious medical malpractice cases. This article aims at the current surge in COVID-19 patients. Using X-ray imaging datasets from COVID-19 patients, previously published on Kaggle as 'RANZCR CLiP - Catheter and Line Position Challenge' and hosted by the Royal Australian and NZ College of Radiologists, a deep-learning algorithm was utilized to detect the position of the patient's catheter and automatically determine whether the catheter tip is misplaced or otherwise. This study employed U-Net to segment and identify catheter position types, together with employing Efficiency net B7 to determine whether the misaligned catheter is misaligned which scores 0.959(AUC). In addition, results were also compared using Efficiency Net B5, ResNet 200D. © 2022 IEEE.

2021: Perioperative and critical care year in review for the cardiothoracic surgery team.

For yet another year, our lives have been dominated by a pandemic. This year in review, we feature an expert panel opinion regarding extracorporeal support in the context of COVID-19, challenging previously held standards. We also feature survey results assessing the impact of the pandemic on cardiac surgical volume. Furthermore, we focus on a single center experience that evaluated the use of pulmonary artery catheters and the comparison of transfusion strategies in the Restrictive and Liberal Transfusion Strategies in Patients With Acute Myocardial Infarction (REALITY) trial. Additionally, we address the impact of acute kidney injury on cardiac surgery and highlight the controversy regarding the choice of fluid resuscitation. We close with an evaluation of dysphagia in cardiac surgery and the impact of prehabilitation to optimize surgical outcomes.

Hospital superbug traced to remote island beach

Anuradha Chowdhary, professor of mycology, Vallabhbhai Patel Chest Institute, University of Delhi, and corresponding author of the study, says that while C. auris isolates found on the beach were multidrug-resistant, those found in the remoter salt marshes of the Andaman islands were not resistant to ordinary anti-fungal drugs. “Thorough screening of patients and their environment is required as also cohorting (putting together) of patients who are colonised by C. auris —since they continuously shed viable yeast cells from their skin and contaminate hospital environments.” The present study notes that a hypothesis published July 2019 in mBiosuggests that C. auris might be native to wetlands and that its emergence as a human pathogen may be linked to the effects of global warming effects on wetlands.

Vascular access teams: a global outlook on challenges, benefits, opportunities, and future perspectives.

BACKGROUND: Specialized vascular access training for medical professionals organized into vascular access teams (VATs) was shown to improve patient outcomes, clinical efficiency, and cost savings. Professional perspectives on VAT benefits, organization, challenges, and opportunities on a global scale remain inadequately explored. Using detailed perspectives, in this study, we explored the global VAT landscape, including challenges faced, clinical and clinico-economic impacts of VATs, with emphasis on underresearched facets of VAT initiation, data dissemination, and metrics or benchmarks for VAT success. METHODS: Semistructured in-depth interviews of 14 VAT professionals from 9 countries and 5 continents were used to elicit qualitative and quantitative information. RESULTS: Catheter insertions (100%) and training (86%) were the most performed VAT functions. Based on a 1-7 scale evaluating observed impacts of VATs, patient satisfaction (6.5) and institutional costs (6.2) were ranked the highest. VAT co-initiatives, advanced technology utilization (6.6), and ongoing member training (6.3) distinctly impacted VAT endeavors. Most institutions (64%) did not have routine mechanisms for recording VAT-related data; however, all participants (100%) stated the importance of sharing data to demonstrate VAT impacts. Time constraints (57%) emerged as one of the major deterrents to data collection or dissemination. The majority (64%) experienced an increased demand or workload for VAT services during the COVID-19 pandemic. CONCLUSIONS: Despite the global variances in VATs and gaps in VAT-related data, all participants unanimously endorsed the benefits of VAT programs. Evaluating the impact of VATs, disseminating VAT-related data, and forging specialized institutional partnerships for data sharing and training are potential strategies to tackle the hurdles surrounding VAT formation and sustenance.