Bedside Tunneled Hemodialysis Catheter Placement in Patients with COVID-19.

BACKGROUND: COVID-19, the syndrome caused by the novel SARS-CoV2, is associated with high rates of acute kidney injury requiring renal replacement therapy (RRT). It is well known that despite the ease of bedside insertion, the use of nontunneled dialysis catheters (NTDCs) is associated with increased complications compared to tunneled dialysis catheters (TDCs). Our objective was to develop a strategy for TDC placement at the bedside to provide effective dialysis access, conserve resources and decrease personnel exposure at our medical center in an epicenter of the COVID-19 pandemic. METHODS: A technique for bedside TDC insertion with ultrasound and plain radiographs in the intensive care unit was developed. Test or clinically COVID-19-positive patients requiring RRT were evaluated for bedside emergent NTDC or nonemergent TDC placement. Patients who underwent NTDC placement were monitored for ongoing RRT needs and were converted to TDC at the bedside after 3-5 days. We prospectively collected patient data focusing on complications and mortality. RESULTS: Of the 36 consultations for dialysis access in COVID-positive patients from March 19 through June 5, 2020, a total of 24 bedside TDCs were placed. Only one patient developed a complication, which was pneumothorax and cardiac tamponade during line placement. In-hospital mortality in the cohort was 63.9%. CONCLUSIONS: Bedside TDC placement has served to conserve resources, prevent complications with transport to and from the operating room, and decrease personnel exposure during the COVID-19 pandemic. This strategy warrants further consideration and could be used in critically ill patients regardless of COVID status.

Beyond the Tip of the Blade: An Investigation of Upper Extremity Machete Injuries in Honduras.

BACKGROUND: Machete injuries constitute a major cause of morbidity in Honduras. In this study, we aimed to determine the incidence, initial management, surgical treatment, and follow-up patterns for machete injuries at the national public hospital in Honduras. Microsurgery in Honduras is currently in transition with limitations at multiple levels. This study aims to provide critical information to better prepare visiting surgeons and establishes a blueprint to improve microsurgical reconstruction. METHODS: A retrospective chart review was performed to identify patients with machete injuries to the upper extremity (UE) who presented to the Hospital Escuela Universitario (HEU) for treatment from 2015 to 2017. Additional microsurgical data was obtained by personal communication with members of the plastic surgery department at the HEU. RESULTS: Complete data was retrieved for 100 patients who presented to the HEU with a UE machete wound. The cohort was male dominated (93%), employed as farmers (47%), and had a mean age of 32.1 years. Violence was the most common mechanism of injury (p < 0.001). The majority of UE machete injuries involved tendon (70%), nerve (28%), and an open fracture (55%). Of the 76% of patients who were scheduled for a follow-up visit, only 25% attended. Within the last calendar year, one replantation, 10 revascularizations at the wrist and forearm level, three microvascular free tissue transfers, and 175 nerve repairs were performed. CONCLUSION: Management of UE machete injuries in Honduras is challenging and requires early recognition of possible injuries to multiple anatomical systems. The majority of injuries required operative intervention. Only a small percentage of patients presented for follow up. A program to streamline care starting at injury recognition up to final follow-up is currently unavailable and needs to be developed to optimize microsurgical care.

Two unique studies highlighting the positive effects of enhanced recovery after surgery (ERAS) pathways on patient care and satisfaction / Dos estudios únicos en los que se destacan los efectos positivos de los protocolos ERAS (Recuperación rápida después de cirugía) para la atención y la satisfacción de los pacientes

Enhanced recovery after surgery (ERAS) programs are clinical pathways designed to "fast-track" patients back to baseline health as quickly as possible after surgery. These perioperative plans were initially conceived by Kehlet1,a surgeon in Europe. Kehlet and Mogensen2 designed surgical interventions to improve patient outcomes in colorectal surgery. The central tenets of ERAS pathways include: minimal fasting time/early satiety, early ambulation, and multimodal analgesia.3 By employing these concepts, they were able to significantly decrease their surgical patient's length of stay without increasing complications.2 Since that time, ERAS programs have expanded to many countries and across other surgical subspecialties with similar results. Other interventions such as pre-operative surgical and anesthetic education, pre-habilitation, optimization of chronic medical conditions, minimizing bowel preparation/fasting times, carbohydrate loading, multimodal analgesia, nausea and vomiting prophylaxis, thromboembolism prophylaxis, standard antibiotics, standardized operative ventilation strategies, goal-directed fluid therapy, early postoperative ingestion of clear fluids, and early ambulation have been incorporated into various ERAS pathways.4 Typical goals of these programs include decreased length of stay, decreased morbidity and mortality, and improved patient secondary outcomes.5 By reducing hospital stay and complications, hospital systems, and patients experience decreased overall costs. 6 In this editorial, I will comment on 2 articles using ERAS pathways to show positive effects on patient care and satisfaction.

Los programas de recuperación mejorada después de la cirugía (ERAS) son vías clínicas diseñadas para "acelerar" a los pacientes para que vuelvan a su estado de salud inicial lo más rápido posible después de la cirugía. Estos planes perioperatorios fueron concebidos inicialmente por Kehlet1, un cirujano en Europa. Kehlet y Mogensen2 diseñaron intervenciones quirúrgicas para mejorar los resultados de los pacientes en cirugía colorrectal. Los principios centrales de las vías ERAS incluyen: tiempo mínimo de ayuno / saciedad temprana, deambulación temprana y analgesia multimodal.3 Al emplear estos conceptos, pudieron disminuir significativamente la duración de la estadía del paciente quirúrgico sin aumentar las complicaciones.2 Desde entonces, ERAS Los programas se han expandido a muchos países y a otras subespecialidades quirúrgicas con resultados similares. Otras intervenciones tales como educación preoperatoria quirúrgica y anestésica, pre-habilitación, optimización de condiciones médicas crónicas, minimización de los tiempos de preparación / ayuno intestinal, carga de carbohidratos, analgesia multimodal, profilaxis de náuseas y vómitos, profilaxis de tromboembolismo, antibióticos estándar, estrategias de ventilación operativa estandarizadas , la fluidoterapia dirigida por objetivos, la ingestión posoperatoria temprana de líquidos claros y la deambulación temprana se han incorporado en varias vías del ERAS.4 Los objetivos típicos de estos programas incluyen la disminución de la duración de la estadía, la disminución de la morbilidad y la mortalidad y la mejora de los resultados secundarios del paciente.5 reducir la estancia hospitalaria y las complicaciones, los sistemas hospitalarios y los pacientes experimentan una reducción de los costos generales. 6 En este editorial, comentaré 2 artículos que utilizan las vías ERAS para mostrar efectos positivos en la atención y satisfacción del paciente.

Vancomycin-resistant enterococci in intensive care hospital settings.

Vancomycin-resistant enterococci (VRE) have recently emerged as a nosocomial pathogen and present an increasing threat to the treatment of severely ill patients in intensive-care hospital settings. We outline results of a study of the epidemiology of VRE transmission in ICUs and define a reproductive number R0; the number of secondary colonization cases induced by a single VRE-colonized patient in a VRE-free ICU, for VRE transmission. For VRE to become endemic requires R0 > 1. We estimate that in the absence of infection control measures R0 lies in the range 3-4 in defined ICU settings. Once infection control measures are included R0 = 0.6, suggesting that admission of VRE-colonized patients can stabilize endemic VRE.