Inpatient venous access practices: PICC culture and the kidney patient.

PURPOSE: Depleted venous access is frequently cited as a reason for low fistula achievement. These quality assurance studies were designed to clarify the interactions between kidney disease, acuity of care and vascular access practices, and define the impact of nephrology intervention. METHODS: The inpatient population at an urban teaching hospital was surveyed three times between May 2010 and May 2012. Data were collected on limb protection and vascular access practices, as well as level of kidney function and level of care. RESULTS: Peripherally inserted central catheter (PICC) insertion consistently exceeded 30% in patients with chronic kidney disease; reasons for insertion were often poorly defined. More than 50% of patients had devices in the nondominant arm; use of limb protection bracelets was rare. An educational intervention designed to increase nephrologist awareness increased limb protection slightly, but did not affect the distribution of vascular access devices. CONCLUSIONS: PICC placement and invasion of the nondominant arm are both frequent in patients with abnormal kidney function, in spite of guidelines discouraging their use. The rate of PICC is higher than that of patients with normal kidney function. Current vascular access practices have substantial potential to affect future fistula rates. Effective vein protection may require participation of the entire medical community.

Characteristics and associated features of persistent post-sympathectomy pain.

OBJECTIVES: The aim of this study is to describe the incidence and characteristics of pain, sensory abnormalities, abnormal body sweating, and pathologic gustatory sweating in pain patients with persistent post-sympathectomy pain. METHODS: A retrospective chart review of a series of consecutive pain patients with persistent post-sympathectomy pain was performed. Inclusion criteria were: (1) sympathectomy performed for the indication of neuropathic pain, and (2) persistent pain after the procedure. Demographic data, patterns of pain before and after sympathectomy, patients' pain drawings, and incidence of pain had been collected concurrently at the time of referral. Additional data regarding sensory findings, surgical details of the sympathectomy, sweat patterns, and incidence of abnormal body sweating and pathologic gustatory sweating were extracted from the patients' charts or obtained in follow-up appointments. RESULTS: Seventeen adults (13 females and 4 males) with a mean age of 37 years (range 25-52) at the time of sympathectomy met the inclusion criteria. Five of the 17 patients experienced temporary pain relief for an average of 4 months (range 2-12 months), 3/17 retained the same pain as before the surgery, 1 patient was cured of her original pain but experienced a new debilitating pain, and 8/17 patients continued to have the same or worse pain in addition to a new or expanded pain. Pathologic gustatory sweating was present in 7/11 patients asked, and abnormal sweating (known as compensatory hyperhidrosis) in 11/13 patients asked. DISCUSSION: The present study does not allow for conclusions about the effectiveness of surgical sympathectomy for neuropathic pain. However, our findings indicate that if the pain persists after the procedure, the complications may be quite serious and at times worse than the problem for which the surgery was originally performed.