A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill.

Intravascular catheters are inserted into almost all critically ill patients. This review provides up-to-date insight into available knowledge on epidemiology and diagnosis of complications of central vein and arterial catheters in ICU. It discusses the optimal therapy of catheter-related infections and thrombosis. Prevention of complications is a multidisciplinary task that combines both improvement of the process of care and introduction of new technologies. We emphasize the main component of the prevention strategies that should be used in critical care and propose areas of future investigation in this field.

Managing dysfunctional central venous access devices: a practical approach to urokinase thrombolysis.

Tunnelled central venous access devices (CVADs) are defined as any intravenous multipurpose catheters placed within the central veins for use in haemodialysis and administration of blood products or chemotherapy in oncology and haematological conditions. Frequent complications include thrombosis and catheter-related infection, which may lead to significant adverse patient outcomes. Once thrombosis is suspected correction should be attempted empirically with thrombolytic agents. Commonly available thrombolytic agents in the UK include urokinase (Syner-Kinase) and alteplase (Cathflo). It is well recognised that urokinase usage differs widely and concerns were raised by clinicians about the variation of dose regimens nationally. The objective of the CVAD Focus Group was to address this issue and offer guidance in the management of suspected thrombosis of CVAD with urokinase using two algorithms for renal and non-renal dysfunctional CVAD and to audit prospectively the outcomes of intervention.

Aportación de la ecografía realizada por enfermería a la exploración del acceso vascular / Contribution of the ultrasound performed by nursing to the exploration of vascular access

En los últimos años, ha comenzado a usarse por parte de enfermería la ecografía vascular en las unidades de diálisis, mejorando el conocimiento del acceso vascular (AV), ayudando en la elección de las zonas de canulación y aumentando la confianza en los AV nuevos o dificultosos. Nuestro objetivo es describir los motivos de exploración del AV con ecógrafo, los hallazgos encontrados y contrastarlos con el servicio de radiología. Es un estudio observacional, descriptivo en 22 pacientes con fistula arteriovenosa (FAV). Diseñamos un registro donde se recogieron los datos de las exploraciones ecográficas y se explotaron con el programa SPSS15. Se realizaron 37 exploraciones en 22 pacientes. Las principales causas de la exploración fueron: dificultad o dolor en las punciones, localización de nuevas zonas de punción, extravasaciones previas, vigilancia en la maduración de la FAV y seguimiento de FAV. Hallamos 35.1% con trombos, 8.1% circulación colateral, 5.4% colecciones/hematomas y 13.5% estenosis. De los 22 pacientes, 6 se derivaron a radiología y se contrastaron 2 estenosis, 1 disminución de flujo y 1 trombo. Las exploraciones ecográficas realizadas por enfermería de forma autónoma se identifican disfunciones del AV aportándonos mayor información sobre el AV (AU)

In recent years, vascular ultrasound has been used in nursing dialysis units, improving knowledge of vascular access (VA), helping in the selection of cannulation zones and increasing confidence in new or difficult VAs. Our objective is to describe the reasons for the exploration of VA with ultrasound, the findings found and contrast them with the radiology service. It is an observational, descriptive study in 22 patients with arteriovenous fistula (AVF). We designed a graph where data from ultrasound scans were collected and exploited with SPSS15. The sample consisted of 22 patients. There were 37 explorations. The main causes of the exploration were mainly difficulty or pain in the punctures followed by the localization of new areas of puncture, previous extravasations, surveillance in the maturation of AVF and follow-up of AVF. We found 35.1% with thrombi, 8.1% collateral circulation, 5.4% collections / hematomas and 13.5% stenosis. Of the 22 patients, 6 were referred to radiology and 2 stenosis, 1 decrease of flow and 1 thrombus were tested. A high number of ultrasound examinations by nursing are carried out autonomously with which AV dysfunctions are identified, contributing more information about AV (AU)

Estudio de la eficacia de sellado en el periodo interdialítico largo para catéteres de hemodiálisis disfuncionantes / Study of sealing efficiency in the long interdialytic period for dysfunctioning hemodialysis catheters

El sellado de los catéteres venosos tunelizados con distintas soluciones se ha utilizado tanto en la prevención como en el tratamiento de complicaciones, sin embargo, no existe la solución ideal. El objetivo del estudio es comparar las complicaciones de de los catéteres disfuncionantes con diferentes pautas de sellado de fin de semana, Urokinasa 10.000 UI vs TauroLock(TM)-U25.000, así como eficacia dialítica de los mismos. Se trata de un estudio observacional longitudinal de cohorte en el que se analizan los casos de infección, trombosis y funcionalidad del catéter tunelizado. Se incluyen sólo los pacientes con catéter disfuncionante que tenían previamente prescrita una pauta de sellado con urokinasa en el periodo interdialítico largo. El periodo de estudio fue de cuatro meses; dos con sellado con 10.000 UI de Urokinasa y dos con sellado de TauroLock(TM)-U25.000. Las medias de Urokinasa vs Taurolidina: flujo sanguíneo, PV, recirculación, KT (53.3/55L), manipulación y dosis extra de urokinasa fueron mejor en el periodo de Taurolock, aunque no se encontraron diferencias estadísticamente significativas. La media de PA es cercana a la significación (p=0.067) mejor también en el periodo de Taurolock. Hubo una diferencia en la media de KT favorable al periodo de Taurolock que no tiene significación estadística y es exclusivo de los pacientes que no necesitaron urokinasa extra. La principal limitación de nuestro estudio es el tamaño muestral que puede ser el responsable en parte, de la ausencia de significación estadística. Son necesarios estudios con mayor número de pacientes (AU)

The sealing of the tunneled venous catheters with different solutions has been used both in prevention and in the treatment of complications, however, there is no ideal solution. The aim of the study is to compare the complications of dysfunctional catheters with different weekend sealing patterns, Urokinase 10,000 IU vs TauroLock(TM) -U25,000, as well as dialytic efficacy of both substances. A longitudinal observational cohort study in which the cases of infection, thrombosis and functionality of the tunneled catheter were analyzed. Only patients with a dysfunctioning catheter who had previously prescribed a sealing pattern with urokinase in the long interdialytic period were included. The study period was four months; two months sealed with 10,000 IU of Urokinase and the other ones, sealed with TauroLock (TM) -U25,000. Urokinase vs Taurolidine averages: blood flow, venous pressure, recirculation, KT (53.3 / 55L), manipulation and extra doses of urokinase were better in the Taurolock period, although no statistically significant differences were found. The mean arterial pressure is close to the significance (p = 0.067), also better in the Taurolock period. There was a difference in the KT mean, favorable to the Taurolock period, which has no statistical significance and is exclusive to patients who did not require extra urokinase. The main limitation of our study is the sample size that may be partly responsible for the absence of statistical significance. Studies with more patients are necessary (AU)

Factores que influyen en la supervivencia de la fístula arteriovenosa interna y su relación con la técnica de punción / Factors which influence the survival of arteriovenous fistula and their relationship to the puncture technique

Introducción: La siguiente revisión bibliográfica se realiza con el propósito de recopilar las causas de fracaso de la fístula arteriovenosa interna, haciendo especial hincapié en la relación entre la técnica de punción y fracaso de la misma, dada la importancia que el manejo y cuidados de enfermería tienen en el acceso vascular del paciente en hemodiálisis. Objetivo: Revisar la producción científica disponible sobre fallo primario o secundario de la fístula arteriovenosa interna. Metodología: Se realizó una revisión sistemática no metaanalítica, con búsqueda de información en las bases de datos Medline, Proquest, Scopus y Google Scholar. Se incluyeron artículos en español, inglés y francés. Resultados: Se revisaron 38 artículos publicados entre el año 2001 y 2016. La mayoría de ellos estudios observacionales. Tras el análisis de todas las variables se encontró que la edad avanzada, el género femenino, estado inflamatorio y de coagulación, la diabetes, episodios de hipotensión, localización y uso de catéter venoso central influyen negativamente en la supervivencia de la fístula arteriovenosa interna. En cuanto a la influencia de las diferentes técnicas de punción de la fístula, en la supervivencia de la misma, no hay datos concluyentes a favor de la ninguna técnica. Conclusiones: Podemos concluir que los factores que influyen negativamente en la supervivencia de la fístula arteriovenosa interna son: edad avanzada, género femenino, diabetes, estado inflamatorio, episodios de hipotensión, localización distal y uso previo de catéter venoso central (AU)

Introduction: The following literature review aims to collect the causes of failure of arteriovenous fistula, with particular emphasis on the relationship between puncture technique and the failure of it, given the importance of management and nursing care in the vascular access of hemodialysis patients. Objective: To review the available scientific literature about the primary or secondary failure of arteriovenous fistula. Methods: A, non-meta-analytic, systematic review was carried out with information search in the following databases: Medline, ProQuest, Scopus and Google Scholar. Articles in Spanish, English and French are included. Results: The review includes 38 articles published between 2001 and 2016. Most of them are observational studies. After analyzing all the variables, we found that older age, female gender, inflammatory and coagulation status, diabetes, episodes of hypotension, location and use of central venous catheter adversely affect the survival of arteriovenous fistula. Regarding the influence of different needling techniques in the survival of the fistula, there is no conclusive evidence in favor of any technique. Conclusions: We can conclude that factors which adversely affect the survival of arteriovenous fistula are: advanced age, female gender, diabetes, inflammatory state, episodes of hypotension, distal location and previous use of central venous catheter (AU)

Secondary prevention strategy of cardiovascular disease using endothelial function testing.

Over the past decades, secondary prevention of cardiovascular (CV) disease has improved and considerably reduced mortality rates. However, there remains a high-rate of new or recurrent CV events in those with established atherosclerotic vascular diseases. Although most of the prevailing therapies target the conventional risk factors, there is notable interindividual heterogeneity in adaptation to risk factors and response to therapies, which affects efficacy. It is desirable to have a methodology for directly assessing the functional significance of atherogenesis, and for managing individual patients based on their comprehensive vascular health. Endothelial function plays a pivotal role in all stages of atherosclerosis, from initiation to atherothrombotic complication. Endothelial function reflects the integrated effect of all the atherogenic and atheroprotective factors present in an individual, and is therefore regarded as an index of active disease process and a significant risk factor for future CV events. Moreover, improvement in endothelial function is associated with decreased risk of CV events, even in the secondary prevention setting. The introduction of endothelial function assessment into clinical practice may trigger the development of a more tailored and personalized medicine and improve patient outcomes. In this review, we summarize current knowledge on the contribution of endothelial dysfunction to atherosclerotic CV disease in the secondary prevention setting. Finally, we focus on the potential of an endothelial function-guided management strategy in secondary prevention.

Implementing evidence-based patient and family education on oral anticoagulation therapy: a community-based participatory project.

AIMS AND OBJECTIVES: This study aimed at developing and implementing evidence-based patient and family education on oral anticoagulation therapy. BACKGROUND: The number of persons with chronic diseases who live at home is increasing. They have to manage multiple diseases and complex treatments. One such treatment is oral anticoagulation therapy, a high risk variable dose medication. Adherence to oral anticoagulation therapy is jeopardised by limited information about the medications, their risk and complications, the impact of individual daily routine and the limited inclusion of family members in education. Hence, improved and tailored education is essential for patients and families to manage oral anticoagulation therapy at home. DESIGN AND METHODS: A community-based participatory research design combined with the Precede-Proceed model was used including a systematic literature review, posteducation analysis, an online nurse survey, a documentation analysis and patient/family interviews. The study was conducted between April 2010-December 2012 at a department of general internal medicine in a teaching hospital in Switzerland. Participants were the department's nursing and medical professionals including the patients and their families. RESULTS: The evidence-based patient and family education on oral anticoagulation therapy emerged comprising a learning assessment, teaching units, clarification of responsibilities of nurse professionals and documentation guidelines. CONCLUSION AND CLINICAL RELEVANCE: The inclusion of the whole department has contributed to the development and implementation of this evidence-based patient family education on oral anticoagulation therapy, which encompasses local characteristics and patient preferences. This education is now being used throughout the department.

Derrame pleural por síndrome de Dressler / No disponible

El síndrome de Dressler (SD) se caracteriza por fiebre, dolor torácico de tipo pleurítico y derrame pericárdico después de 2-3 semanas de un infarto agudo del miocardio o lesión pericárdica; suele mejorar con AAS u otro AINE; los glucocorticoides se reservan para pacientes con dolor intenso y refractario. Se presenta el caso de un varón con derrame pleural (DP) secundario a SD en paciente con antecedente de cirugía cardiaca reciente recidivante y con mala evolución, en probable relación a tratamiento con dosis bajas de antiinflamatorios y rápido descenso de los mismos de forma inicial, presentando mejoría al reintroducir tratamiento a dosis altas y de forma prolongada

Dressler’s syndrome (DS) is characterized by fever, chest pleuritic pain and pericardial effusion that may appear 2-3 weeks after an acute myocardial infarction or pericardial injury and usually improves with aspirin or other NSAIDs; glucocorticoids reserved for patients with severe and refractory pain. The case of a man with pleural effusion (PE) secondary to DS with history of recent heart surgery, which was recurrent and poor outcome, probably related to treatment with low doses of anti-inflammatory and rapid decline of the same initial presenting improvement to reintroduce treatment with high doses and for long periods

European cardiac nurses' current practice and knowledge on anticoagulation therapy.

BACKGROUND: Successful management of warfarin, new anti-thrombotic agents and self-monitoring devices requires that health care professionals effectively counsel and educate patients. Previous studies indicate that health care professionals do not always have the knowledge to provide patients with the correct information. AIMS: The purpose of this study was to investigate European cardiovascular nurses' knowledge on the overall management of anticoagulation therapy and examine if this knowledge was influenced by level of education and years in clinical practice. METHODS: A questionnaire including 47 items on practice patterns and knowledge on warfarin, new anticoagulants, warfarin-drug and warfarin-food interactions, and self-management of International Normalized Ratio (INR) was distributed to the attendants at a European conference in 2012. RESULTS: The response rate was 32% (n=206), of whom 84% reported having direct patient contact. Warfarin was the most common used oral anticoagulation in daily practice. One third offered their patients both patient self-testing and patient self-management of INR. The mean total score on the knowledge questions was 28±6 (maximum possible score 53). Nurses in direct patient care had a higher mean score (p=0.011). Knowledge on warfarin and medication-interactions were low, but knowledge on warfarin-diet interactions and how to advise patients on warfarin as somewhat better. CONCLUSION: European cardiac nurses need to improve their knowledge and practice patterns on oral anticoagulation therapy. This area of knowledge is important in order to deliver optimal care to cardiac patients and to minimise adverse effects of the treatment.

Preventing and managing complications of CVADs.

Patient assessment and the appropriate management of long-term central venous access devices are essential to diminishing the potential for complications. When complications do occur, they tend to be the consequence of a series of events. Recognising problems at an early stage means they can be addressed sooner and improves the chances of resolving them without any long-term consequences.

Utilization of low-molecular-weight heparin prophylaxis in pediatric and adolescent trauma patients.

The objective of this study was to use trauma registry data to describe the number and characteristics of patients 21 years or younger receiving thromboprophylaxis with low-molecular-weight heparin at 2 pediatric and 2 adult level 1 trauma centers. Among 706 patients, the average age was 18.5 years, and 94.6% were hospitalized at adult centers. The most common injuries were lower extremity fractures (35.6%) and head injuries (20.4%). Major bleeding was reported in 3 patients (0.4%), and thrombotic events were reported in 15 patients (2.1%). Despite a lack of scientific evidence, low-molecular-weight heparin prophylaxis is being used in young trauma patients (primarily those 14 years or older). Prospective multicenter studies are needed to accurately describe the risks and benefits of low-molecular-weight heparin prophylaxis in young trauma patients, thereby identifying those who truly benefit from this intervention.

The importance of ideal central venous access device tip position.

The use of central venous access devices (CVADs) is becoming more common in hospitals and the community. Incorrect tip placement is a common complication of CVAD insertion carried out at the bedside, and can lead to local inflammation and thrombosis. The literature recommends that a CVAD tip should be in the lower third of the superior vena cava. Anyone inserting a CVAD needs to take account of body position changes that may cause a tip to move. There are many tools and systems nurses can use to aid tip positioning, including taking body measurements, using body landmarks and electrocardiograms (ECGs). Tip position must be checked on a chest X-ray. There are several ways to determine tip postion and electromagnetic catheter tip guidance machines are being developed in the USA, which can record the position of a tip with greater accuracy. Nurses inserting CVADs at the bedside must appreciate the risks that incorrect or suboptimal tip position pose to the patient.

How data can help reduce vascular access events.

Thrombosis is the leading cause of access dysfunction and is expensive to treat. In 2011, only 10 AV access capable patients in our center were placed on a bridge catheter because of our ability to assess health and proactively use angioplasty to keep it open. Surveillance also helped us follow the progression of new fistula maturation and helped us decide on early intervention to prevent total, access failure. The Sparrow Center documented successful results with the selection of a new surveillance system that dramatically improved the quality of patient care and financial viability of the center. For dialysis center staffs looking for ways to operate more efficiently and at the same time reduce the incidence of vascular access complications caused by thrombosis, a data-driven surveillance device along with clinical monitoring protocols seems to provide a cost effective approach to addressing this critical area of patient care.