Incidence, complications, and costs of peripheral venous catheter-related bacteraemia: a retrospective, single-centre study.

BACKGROUND: Peripheral venous catheter (PVC) complications occur on average in approximately half of patients, necessitating premature PVC removal, suspending administration of ongoing therapies, and catheter replacement. AIM: To estimate the current incidence, complications, and costs of bloodstream infection (BSI) attributable to PVCs. METHODS: Patients with PVC-related BSI (cases) were matched with patients without PVC-related BSI (controls). FINDINGS: From January 1st, 2018 to March 31st, 2020, a total of 9833 out of 113,068 patients visiting the emergency department (9%) were hospitalized in a medical ward after insertion of a PVC. Among them, 581 (6%) had at least one positive blood culture. Twenty-five (4%) of these were judged as having a PVC-related BSI. Major complications were noted in nine patients. One patient presented severe sepsis requiring admission to intensive care unit for eleven days followed by thoracic (T4-T7) spondylodiscitis requiring prolonged antimicrobial therapy. Another patient developed mitral valve endocarditis also requiring prolonged antimicrobial therapy. One patient developed a pre-sacral abscess three months after initial PVC infection and required hospital readmission for 19 days for drainage. Median (interquartile range) hospital stay costs were €11,597 (8,479-23,759) for cases and €6,789 (4,019-10,764) for controls, leading to median additional costs of €5,587. CONCLUSION: Though the risk of developing PVC-related BSI in patients admitted to medical wards may seem low, complications of PVC-related BSI are severe, and associated mortality remains high. The financial resources used to treat these complications could be better spent on prevention, including the use of high-quality materials and technologies, and improved training of healthcare providers.

Photography tele-transmission by regular ambulance staff for the management of mild traumatic injury: the NiCEPHORE randomised-controlled trial.

BACKGROUND: Handling emergency calls in French emergency medical call centres (EMCCs) can be challenging considering the frequent lack of relevant information. Tele-transmission device use in regular ambulances seems like a good solution to provide the EMCC physician with a more accurate assessment of the scene, particularly for mild traumatic injury (MTI). We measured the impact of ambulance staff tele-transmitted photography on prehospital dispatching optimisation for patients calling the EMCC with MTI. METHODS: We conducted a prospective, single-centre, randomised-controlled trial comparing two groups of patients calling the EMCC with MTI who were or were not allocated to photography tele-transmission by ambulance staff. The primary outcome was the proportion of patients referred away from the nearest hospital (left at home for outpatient care; referred to a higher-level hospital; handled by a medical intensive care ambulance for advanced pre-hospital care) used as a marker of better orientation. RESULTS: Between 29 April 2019 and 21 July 2020, 165 patients were randomised and 152 analysed. Photography tele-transmission resulted in better patient dispatching (24/73 [33%] patients in the intervention group vs 9/79 [11%] patients in the control group, OR 3.80 [1.63-8.90]; p = 0.03), without increasing the proportion of patients initially left at home for outpatient care and visiting an ED within 10 days for secondary trauma-related care (1/14 [7%] vs 1/4 [25%], OR 0.25 [0.01-24.1]; p = 0.41). The proportion of patients unnecessarily referred to an ED was 7% [4/59 patients] in the intervention group vs 16% [12/75 patients] in the control group (OR 0.38 [0.09-1.36]; p = 0.10). CONCLUSION: Photography tele-transmission by regular ambulance staff could improve the dispatching of patients calling French EMCCs with MTI. Trial registration The study is registered with Clinicaltrials.gov (NCT04034797).

Peripheral venous catheter colonization after skin disinfection with 0.5% aqueous sodium hypochlorite, preceded or not by one application of 70% ethanol (DACLEAN): a single-centre, randomized, open-label, pilot study.

Few data are available on the efficacy of 0.5% aqueous sodium hypochlorite (SH) for skin disinfection before peripheral catheter insertion. A total of 239 patients were randomly assigned to either one application of SH alone or one application of SH preceded by one application of 70% ethanol (ET-SH). Catheter colonization, defined as a catheter tip culture growing >1000 cfu of a micro-organism per millilitre, occurred in 29 patients (33% of 89 colonizations per 1000 catheter-days) in the SH group and in 31 patients (33% of 126 colonizations per 1000 catheter-days) in the ET-SH group.

Validity of surrogate endpoints assessing central venous catheter-related infection: evidence from individual- and study-level analyses.

OBJECTIVES: The prevention of catheter-related bloodstream infection (CRBSI) has been an area of intense research, but the heterogeneity of endpoints used to define catheter infection makes the interpretation of randomized controlled trials (RCTs) problematic. The aim of this study was to determine the validity of different endpoints for central venous catheter infections. DATA SOURCES: (a) Individual-catheter data were collected from 9428 catheters from four large RCTs; (b) study-level data from 70 RCTs were identified with a systematic search. Eligible studies were RCTs published between January 1987 and October 2018 investigating various interventions to reduce infections from short-term central venous catheters or short-term dialysis catheters. For each RCT the prevalence rates of CRBSI, quantitative catheter tip colonization, catheter-associated infection (CAI) and central line-associated bloodstream infection (CLABSI) were extracted for each randomized study arm. METHODS: CRBSI was used as the gold-standard endpoint, for which colonization, CAI and CLABSI were evaluated as surrogate endpoints. Surrogate validity was assessed as (1) the individual partial coefficient of determination (individual-pR2) using individual catheter data; (2) the coefficient of determination (study-R2) from mixed-effect models regressing the therapeutic effect size of the surrogates on the effect size of CRBSI, using study-level data. RESULTS: Colonization showed poor agreement with CRBSI at the individual-patient level (pR2 = 0.33 95% CI 0.28-0.38) and poor capture at the study level (R2 = 0.42, 95% CI 0.21-0.58). CAI showed good agreement with CRBSI at the individual-patient level (pR2 = 0.80, 95% CI 0.76-0.83) and moderate capture at the study level (R2 = 0.71, 95% CI 0.51-0.85). CLABSI showed poor agreement with CRBSI at the individual patient level (pR2 = 0.34, 95% CI 0.23-0.46) and poor capture at the study level (R2 = 0.28, 95% CI 0.07-0.76). CONCLUSIONS: CAI is a moderate to good surrogate endpoint for CRBSI. Colonization and CLABSI do not reliably reflect treatment effects on CRBSI and are consequently more suitable for surveillance than for clinical effectiveness research.

Value of copeptin and the S-100b protein assay in ruling out the diagnosis of stroke-induced dizziness pattern in emergency departments.

BACKGROUND: Dizziness is a frequent reason for visiting emergency departments (EDs). Differentiating stroke from other causes is challenging for physicians. The role of biomarkers has been poorly assessed. We evaluated whether copeptin and S100b protein (PS100b) assessment, alone or in combination, could rule out stroke in patients visiting EDs for dizziness. METHODS: We included patients 18 years of age or older, visiting the adult ED of a French university hospital for a new episode of dizziness evolving for less than 72 h. All patients underwent standardized physical examination (HINT [Head Impulse test, Nystagmus, test of skew deviation] maneuvers), copeptin and S-100b protein (PS100) measurement and injected brain imaging. Stroke diagnosis involved diffusion-weighted magnetic resonance imaging or, if not available, neurological examination and contrast brain CT scan compatible with the diagnosis. RESULTS: Of the 135 patients participating in the study, 13 (10%) had stroke. The sensitivity, specificity and positive and negative predictive values of copeptin/PS100 combination were 100% (95%CI, 77-100%), 48% (40-57%), 14% (11-27%) and 100% (94-100%), respectively. Values for copeptin alone were 77% (CI95% 0.50-0.91), 50% (CI95% 0.49-0.58), 14% (CI95% 0.08-0.24), 93% (CI95% 0.87-0.98), and for PS100 alone were 54% (CI95% 0.29-0.77), 97% (CI95% 0.92-0.99), 64% (CI95% 0.35-0.84), 95% (CI95% 0.90-0.98). CONCLUSIONS: Absence of copeptin and PS100 elevation seems to ruling out the diagnosis of stroke in patients visiting the ED for a new episode of dizziness. These results need to be confirmed in a large-scale study.

Cardiac output monitoring with thermodilution pulse-contour analysis vs. non-invasive pulse-contour analysis.

Intravenous fluid boluses guided by changes in stroke volume improve some outcomes after major surgery, but invasive measurments may limit use. From October 2016 to May 2018, we compared the agreement and trending ability of a photoplethysmographic device (Clearsight) with a PiCCO, calibrated by thermodilution, for haemodynamic variables in 20 adults undergoing major elective surgery. We analysed 4519 measurement pairs, including before and after 68 boluses of 250 ml crystalloid. The bias and precision of stroke volume measurement by Clearsight were -0.89 ± 4.78 ml compared with the invasive pulse-contour cardiac output device. The coefficient of agreement for stroke volume variation after fluid boluses between the two devices was 0.79 ('strong'). Fluid boluses that increased stroke volume by ≥ 10% increased mean absolute volume (SD) and mean percentage (SD) stroke volume measurements similarly for the invasive pulse-contour cardiac output and Clearsight devices: 9 (4) ml vs. 8 (4) ml and 16% (8%) vs. 15% (10%), respectively, p > 0.05. The non-invasive Clearsight pulse-contour analysis was similar to an invasive pulse-contour device in measuring absolute and changing stroke volumes during major surgery.

Antibioprophylaxis in surgery and interventional medicine (adult patients). Update 2017.

Infection is a risk for any intervention. In surgery, for example, pathogenic bacteria are found in more than 90% of operative wounds during closure. This exists whatever the surgical technique and whatever the environment (the laminar flow does not entirely eliminate this risk). These bacteria are few in number but can proliferate. They find in the operative wound a favourable environment (haematoma, ischaemia, modification of oxido-reduction potential...) and the intervention induces anomalies of the immune defences. In the case of the installation of foreign material, the risk is increased. The objective of antibiotic prophylaxis (ABP) is to prevent bacterial growth in order to reduce the risk of infection at the site of the intervention. The preoperative consultation represents a privileged moment to decide on the prescription of a ABP. It is possible to define the type of intervention planned, the associated risk of infection (and therefore the necessity or not of ABP), the time of prescription before surgery and any allergic antecedents which may modify the choice of the selected antibiotic molecule.

Use of intra-osseous access in adults: a systematic review.

BACKGROUND: Indications for intra-osseous (IO) infusion are increasing in adults requiring administration of fluids and medications during initial resuscitation. However, this route is rarely used nowadays due to a lack of knowledge and training. We reviewed the current evidence for its use in adults requiring resuscitative procedures, the contraindications of the technique, and modalities for catheter implementation and skill acquisition. METHODS: A PubMed search for all articles published up to December 2015 was performed by using the terms "Intra-osseous" AND "Adult". Additional articles were included by using the "related citations" feature of PubMed or checking references of selected articles. Editorials, comments and case reports were excluded. Abstracts of all the articles that the search yielded were independently screened for eligibility by two authors and included in the analysis after mutual consensus. In total, 84 full-text articles were reviewed and 49 of these were useful for answering the following question "when, how, and for which population should an IO infusion be used in adults" were selected to prepare independent drafts. Once this step had been completed, all authors met, reviewed the drafts together, resolved disagreements by consensus with all the authors, and decided on the final version. RESULTS: IO infusion should be implemented in all critical situations when peripheral venous access is not easily obtainable. Contraindications are few and complications are uncommon, most of the time bound to prolonged use. The IO infusion allows for blood sampling and administration of virtually all types of fluids and medications including vasopressors, with a bioavailability close to the intravenous route. Unfortunately, IO infusion remains underused in adults even though learning the technique is rapid and easy. CONCLUSIONS: Indications for IO infusion use in adults requiring urgent parenteral access and having difficult intravenous access are increasing. Physicians working in emergency departments or intensive care units should learn the procedures for catheter insertion and maintenance, the contraindications of the technique, and the possibilities this access offers.

Population Pharmacokinetics of Colistin Methanesulfonate and Colistin in Critically Ill Patients with Acute Renal Failure Requiring Intermittent Hemodialysis.

Colistin is increasingly used as a last option for the treatment of severe infections due to Gram-negative bacteria in critically ill patients requiring intermittent hemodialysis (HD) for acute renal failure. Our objective was to characterize the pharmacokinetics (PK) of colistin and its prodrug colistin methanesulfonate (CMS) in this population and to suggest dosing regimen recommendations. Eight intensive care unit (ICU) patients who were under intermittent HD and who were treated by CMS (Colimycine) were included. Blood samples were collected between two consecutive HD sessions. CMS and colistin concentrations were measured by a specific chromatographic assay and were analyzed using a PK population approach (Monolix software). Monte Carlo simulations were conducted to predict the probability of target attainment (PTA). CMS nonrenal clearance was increased in ICU-HD patients. Compared with that of ICU patients included in the same clinical trial but with preserved renal function, colistin exposure was increased by 3-fold in ICU-HD patients. This is probably because a greater fraction of the CMS converted into colistin. To maintain colistin plasma concentrations high enough (>3 mg/liter) for high PTA values (area under the concentration-time curve for the free, unbound fraction of a drug [fAUC]/MIC of >10 and fAUC/MIC of >50 for systemic and lung infections, respectively), at least for MICs lower than 1.5 mg/liter (nonpulmonary infection) or 0.5 mg/liter (pulmonary infection), the dosing regimen of CMS should be 1.5 million international units (MIU) twice daily on non-HD days. HD should be conducted at the end of a dosing interval, and a supplemental dose of 1.5 MIU should be administered after the HD session (i.e., total of 4.5 MIU for HD days). This study has confirmed and complemented previously published data and suggests an a priori clear and easy to follow dosing strategy for CMS in ICU-HD patients.

Appropriate dosing of sugammadex to reverse deep rocuronium-induced neuromuscular blockade in morbidly obese patients.

In morbidly obese patients, the speed of reversal of neuromuscular blockade with sugammadex based on ideal body weight is still matter of debate. In this single-center, randomised, double-blinded study, neuromuscular blockade was monitored in 50 patients using acceleromyography at the adductor pollicis. At the end of surgery with deep rocuronium-induced neuromuscular blockade, patients randomly received sugammadex 4 mg.kg(-1) (high dose group), 2 mg.kg(-1) (middle dose group), or 1 mg.kg(-1) (low dose group) of ideal body weight. After administration of the first dose of sugammadex, the mean (SD) recovery time (censored at 600 s) from deep neuromuscular blockade was significantly shorter (p < 0.001) in the high-dose group (n = 14; 255 (63) s) vs the middle-dose group (n = 13; 429 (102) s), or low-dose group (n = 4; 581 (154) s). Success rate from neuromuscular blockade reversal defined by a train-of-four ≥ 0.9 within 10 min after sugammadex administration, were 93%, 77% and 22% for these high, middle and low-dose groups respectively (p < 0.05 vs low-dose group). In morbidly obese patients, 4 mg.kg(-1) of ideal body weight of sugammadex allows suitable reversal of deep rocuronium-induced neuromuscular blockade. Monitoring remains essential to detect residual curarisation or recurarisation.

Preoperative hair removal and surgical site infections: network meta-analysis of randomized controlled trials.

Preoperative hair removal has been used to prevent surgical site infections (SSIs) or to prevent hair from interfering with the incision site. We aimed to update the meta-analysis of published randomized controlled trials about hair removal for the prevention of SSIs, and conduct network meta-analyses to combine direct and indirect evidence and to compare chemical depilation with clipping. The PubMed, ScienceDirect and Cochrane databases were searched for randomized controlled trials analysing different hair removal techniques and no hair removal in similar groups. Paired and network meta-analyses were conducted. Two readers independently assessed the study limitations for each selected article according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. Nineteen studies met the inclusion criteria. No study compared clipping with chemical depilation. Network meta-analyses with shaving as the reference showed significantly fewer SSIs with clipping, chemical depilation, or no depilation [relative risk 0.55, 95% confidence interval 0.38-0.79; 0.60, 0.36-0.97; and 0.56, 0.34-0.96, respectively]. No significant difference was observed between the absence of depilation and chemical depilation or clipping (1.05, 0.55-2.00; 0.97, 0.51-1.82, respectively] or between chemical depilation and clipping (1.09, 0.59-2.01). This meta-analysis of 19 randomized controlled trials confirmed the absence of any benefit of depilation to prevent surgical site infection, and the higher risk of surgical site infection when shaving is used for depilation. Chemical depilation and clipping were compared for the first time. The risk of SSI seems to be similar with both methods.

Continuous monitoring of haemoglobin concentration after in-vivo adjustment in patients undergoing surgery with blood loss.

Non-invasive monitoring of haemoglobin concentration provides real-time measurement of haemoglobin concentration (SpHb) using multi-wavelength pulse co-oximetry. We hypothesised that in-vivo adjustment using the mean of three haemoglobinometer (HemoCue®) measurements from an arterial blood sample at the first SpHb measurement (HCueART) would increase the accuracy of the monitor. The study included 41 adults for a total of 173 measurements of haemoglobin concentration. In-vivo adjusted SpHb was automatically calculated by the following formula: in-vivo adjusted SpHb = unadjusted SpHb - (SpHb - HCueART). The accuracy of in-vivo adjusted SpHb was compared with SpHb retrospectively adjusted using the same formula, except for haemoglobin level which was assessed at the central laboratory and then compared with all other available invasive methods of haemoglobin measurement (co-oximetry, HbSAT; arterial HemoCue, HCueART; capillary HemoCue, HCueCAP). Compared with laboratory measurement of haemoglobin concentration, bias (precision) for unadjusted SpHb, in-vivo adjusted SpHb, retrospectively adjusted SpHb, HbSAT, HCueART and HCueCAP were -0.4 (1.4), -0.3 (1.1), -0.3 (1.1), -0.6 (0.7), 0.0 (0.4) and -0.5 (1.2) g.dl(-1) , respectively. In-vivo adjustment of SpHb values using the mean of three arterial HemoCue measurements improved the accuracy of the device similar to those observed after a retrospective adjustment using central laboratory haemoglobin level.

Comparison of acoustic and impedance methods with mask capnometry to assess respiration rate in obese patients recovering from general anaesthesia.

Respiratory depression, a potentially serious complication after general anaesthesia, can be detected promptly by close monitoring of both oxygen saturation and respiratory rate. Obese patients have morphological changes that may impair the reliability of monitoring devices. In this study, respiration rate was simultaneously recorded every second for up to 60 min using a computer in 30 adult obese patients (body mass index ≥ 35 kg.m(-2)), by three methods: acoustic; thoracic impedance; and capnometry via a facemask (Capnomask, reference method). Of the 99,771 data triplets collected, only 85,520 (86%) were included; 12,021 (84%) were not studied due to failure of capnometry and 2240 (16%) due to failure of the acoustic method. Compared with capnometry, bias was similar using both the acoustic method and impedance (-0.3 bpm vs. -0.6 bpm, respectively, p = 0.09), but limits of agreement were narrower for the acoustic method (±3.5 bpm vs. ±5.3 bpm, respectively, p = 0.0008). The proportion of respiration rate values obtained with the acoustic method and impedance that differed by at least 10% or 20% for more than 15 s were 11% vs. 23% and 2% vs. 6%, respectively (p = 0.0009 for both comparisons). The acoustic sensor was well tolerated, while the facemask was pulled off on several occasions by four (13%) agitated patients. In obese patients requiring close monitoring of respiration rate, the acoustic method may be more precise than thoracic impedance and better tolerated than capnometry with a facemask.

Is surgical site scrubbing before painting of value? Review and meta-analysis of clinical studies.

BACKGROUND: Surgical site infections are major surgical complications. Surgical site scrubbing before painting is controversial. AIM: To conduct a meta-analysis of clinical trials that compared pre-operative scrubbing before painting with painting alone for the prevention of surgical site infections. METHODS: A systematic review and meta-analysis of clinical trials in Pubmed, ScienceDirect and Cochrane databases that compared pre-operative scrubbing before painting with painting alone, and reported surgical site infections, skin colonization or adverse effects as an outcome, was undertaken. A fixed-effect model and a random-effect model were tested. Sensitivity analysis was conducted by removing non-randomized controlled trials. FINDINGS: The systematic review identified three studies, involving 570 patients, for surgical site infection outcomes, and four other studies, involving 1082 patients, for positive skin culture outcomes. No significant differences were observed between scrubbing before painting vs painting alone in terms of surgical site infection or positive skin culture. CONCLUSION: Further research is needed to draw conclusions. Only one study in this meta-analysis identified adverse effects, but there were too few events to compare the various methods. It is believed that there is no need to scrub the surgical site if the skin is visibly clean and/or if the patient has had a pre-operative shower.

New colistin population pharmacokinetic data in critically ill patients suggesting an alternative loading dose rationale.

Colistin is an old antibiotic that has recently gained a considerable renewal of interest as the last-line defense therapy against multidrug-resistant Gram-negative bacteria. It is administered as colistin methanesulfonate (CMS), an inactive prodrug, and it was shown that due to slow CMS conversion, colistin plasma concentrations increase very slowly after treatment initiation, which constitutes the rationale for a loading dose in critically ill patients. However, faster CMS conversion was observed in healthy volunteers but using a different CMS brand, which may also have a major impact on colistin pharmacokinetics. Seventy-three critically ill patients not undergoing dialysis received multiple doses of CMS. The CMS concentrations were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and a pharmacokinetic analysis was conducted using a population approach. We confirmed that CMS renal clearance and colistin concentrations at steady state are mostly governed by creatinine clearance, but we predict a typical maximum concentration of drug in serum (Cmax) of colistin close to 2 mg/liter, occurring 3 h after an initial dose of 2 million international units (MIU) of CMS. Accordingly, the estimated colistin half-life (t1/2) was relatively short (3.1 h), with rapid attainment of steady state. Our results are only partially consistent with other recently published results. We confirm that the CMS maintenance dose should be adjusted according to renal function in critically ill patients. However, much higher than expected colistin concentrations were observed after the initial CMS dose, with rapid steady-state achievement. These discrepancies challenge the pharmacokinetic rationale for a loading dose, which may still be appropriate for rapid bacterial eradication and an improved clinical cure rate.

[Update of the 2013 consensus conference "Management of the preoperative risk of infection"]. / Mise à jour 2013 de la conférence de consensus « Gestion préopératoire du risque infectieux ¼

UNLABELLED: The surgical site infections (SSI) are rare adverse events that may have severe consequences in terms of morbidity, mortality and costs. Guidelines on the preparation of the patient can reduce the risk of SSI. Previous guidelines were published in 2004. MATERIAL: A steering committee and a group of experts were established after seeking professional societies that had participated in the previous guidelines. The working group has defined the objectives of revising and retained two main themes: skin preparation and nasal decolonization of patients with Staphylococcus aureus. We chose to report only the work done on the patient skin preparation. The working group relied on the method of recommendation for clinical practice of the High Authority for Health (HAS). The GRADE approach was used to analyze the articles published since 2004. RESULTS: It is recommended to perform a preoperative shower but when does not matter. The use of a simple soap seems sufficient. Shampoo does not seem essential nor removal of varnish in the field of urology. Impregnated fabrics, adhesives fields and bacteriological insulating films are of little use to reduce the risk of infection. The depilation is not routinely required. It is recommended to perform a cleansing on contaminated skin. The use of an alcohol antiseptic is preferred, the successive application of two different antiseptics range is possible. CONCLUSIONS: The updated guidelines on the patient skin preparation before urological surgery was necessary. It changed some guidelines that should appear in our daily practice.