Peripherally Inserted Central Catheter Versus Centrally Inserted Central Catheter for In-Hospital Infusion Therapy: A Cost-Effectiveness Analysis.

OBJECTIVES: To evaluate the comparative effectiveness and cost-effectiveness of peripherally inserted central catheters (PICCs) compared with centrally inserted central catheters (CICCs). METHODS: Prospective cohort study was followed by an economic analysis over a 30-day time horizon. Propensity score matching was used to select hospitalized adults with similar indications for PICC or CICC. The composite outcome was device removal or replacement because of complications before the end of treatment. The economic evaluation was based on a decision tree model for cost-effectiveness analysis, with calculation of the incremental cost-effectiveness ratio (ICER) per catheter removal avoided. All costs are presented in Brazilian reais (BRL) (1 BRL = 0.1870 US dollar). RESULTS: A total of 217 patients were followed in each group; 172 (79.3%) of those receiving a PICC and 135 (62.2%) of those receiving a CICC had no device-related complication, respectively. When comparing the events leading to device removal, the risk of composite endpoint was significantly higher in the CICC group (hazard ratio 0.20; 95% CI 0.11-0.35). The cost of PICC placement was BRL 1290.98 versus BRL 467.16 for a CICC. In the base case, the ICER for placing a PICC instead of a CICC was BRL 3349.91 per removal or replacement avoided. On univariate sensitivity analyses, the model proved to be robust within an ICER range of 2500.00 to 4800.00 BRL. CONCLUSIONS: PICC placement was associated with a lower risk of complications than CICC placement. Although the cost of a PICC is higher, its use avoided complications and need for catheter replacement before the end of treatment.

Transradial artery access for carotid artery stenting: A pooled analysis.

INTRODUCTION: Carotid artery stenting (CAS) through transradial access (TRA) is emerging as an alternative to carotid endarterectomy. However, the current evidence base is limited, mainly comprising single-center studies. OBJECTIVE: This systematic review and meta-analysis aim to assess the safety and effectiveness of TRA for CAS, providing evidence to support clinical decisions. METHODS: We conducted searches on PUBMED, Cochrane Library, Embase, and Web of Science databases, including studies on TRA for CAS. Studies with fewer than 20 patients, non-primary outcomes, and non-full-text articles were excluded. RESULTS: We analyzed 14 studies involving 1,166 patients who underwent CAS via TRA. Procedural success rate was high in 13 studies, with a 95% rate (95% CI; 92%-98%). Crossover to TFA access was observed in 12 studies at 6% (95% CI: 3%-9%). Transradial access failure was reported in four studies, with a rate of 0% (95% CI: 0%-0%). Cannulation failure resulted in a rate of 4% (95% CI: 2%-7%). Asymptomatic radial artery occlusion (ARAO) occurred at a rate of 2% based on eight studies (95% CI: 0%-5%). Forearm hematoma was reported in 10 studies, with an occurrence of 1% (95% CI: 0%-2%). Cerebral vascular attacks (CAV) within 30 days were assessed in 13 studies, indicating a 2% occurrence (95% CI: 1%-2%). CONCLUSION: The findings suggest that TRA for CAS yields promising outcomes with high success rates and low complication rates. Further research should focus on randomized controlled trials and long-term outcomes to validate and extend findings.

Patrulla de catéteres: Análisis de la implementación de un equipo de colocación de catéteres percutáneos como estrategia menos invasiva para la terapia intravenosa / Catheter patrol: analysis of the implementation of a percutaneous catheter placement team as a less invasive strategy for intravenous therapy

En el año 2008 se creó el equipo de patrulla de catéteres para la colocación de catéteres percutáneos por punción directa para pacientes pediátricos en el Hospital de Pediatría Juan P. Garrahan, como estrategia para el cumplimiento de la terapia intravenosa. Diseño: Cohorte retrospectiva. Objetivo: evaluar resultados de la implementación de la patrulla de catéteres entre 2009 y 2013. Se analizaron factores asociados a complicaciones. Criterios de inclusión: catéteres colocados en unidades de cuidados intermedios por Enfermería de patrulla de catéteres en niños con edad entre 31 días a 17 años. Resultados: 2121 catéteres, 1,6 catéteres/paciente, edad mediana 6 años (r 1m- 17 años), permanencia mediana 9 días (7-12). Complicaciones más frecuentes: obstrucción 27,19%, desplazamiento 25,94%,ruptura 11,76%, traccionado por el paciente 11,08%, bacteriemia asociada a catéter 1,62 a 2,80 por 1000 días /catéter. La tasa de incidencia de complicaciones en los menores de 1 año fue 39,92 días catéter mientras que en los mayores de 1 año 31,14 días catéter; p=0,002, diámetro en fr y relación con complicaciones: 4fr 12,17 días/catéter, 3fr 24,25 días/catéter y 2fr 42,27dias/catéter, (p=0,000), no hubo diferencias según cantidad de lúmenes. Conclusiones: los resultados de este estudio sugieren que la edad del paciente, el tipo de cuidado y contención inciden en las complicaciones. Los dispositivos de aseguramiento deberán estar acordes a las necesidades y características del niño (AU)

In 2008, the catheter patrol team was created for the placement of percutaneous catheters by direct puncture for pediatric patients at Hospital de Pediatría Juan P. Garrahan, as a strategy to increase compliance with intravenous therapy. Design: Retrospective cohort study. Objective: to evaluate the results of the implementation of a catheter patrol between 2009 and 2013. Factors associated with complications were analyzed. Inclusion criteria: catheters placed in intermediate care units by catheter patrol nurses in children aged 31 days to 17 years. Results: 2121 catheters, 1.6 catheters/patient, median age 6 years (r 1m- 17 years), median stay 9 days (7-12). Most frequent complications: obstruction 27.19%, displacement 25.94%, rupture 11.76%, accidental pull-out by the patient 11.08%, catheter-associated bacteremia 1.62 to 2.80 per 1000 catheter-days. The incidence rate of complications in children under 1 year of age was 39.92 catheter-days while in those older than 1 year it was 31.14 catheter-days (p=0.002). Relationship between fr diameter and complications: 4fr 12.17 catheter-days, 3fr 24.25 catheter-days, and 2fr 42.27 catheter-days (p=0.000); there were no differences according to the number of lumens. Conclusions: the results of this study suggest that the age of the patient, the type of care, and containment have an impact on complications. Securement devices should be in agreement with the needs and characteristics of the child (AU)

Análise do efeito da padronização das medidas de prevenção de infeção da corrente sanguínea relacionada ao cateter central de inserção periférica em recém-nascidos na unidade de terapia intensiva neonatal / Analysis of the effect of standardization of bloodstream infection prevention measures related to peripherally inserted central catheters in newborns in the neonatal intensive care unit

Introdução: O uso do cateter central de inserção periférica na Neonatologia tem contribuídosignificativamente para reduzir a mortalidade neonatal nas Unidades de Terapia IntensivaNeonatais. Essa prática intravenosa segura favorece a estabilização hemodinâmica do recémnascido e possibilita a administração de drogas vesicantes, irritantes e de nutrição parenteral.O objetivo principal deste estudo foi de analisar o efeito da padronização das medidas deprevenção de infecção durante a inserção e o manuseio do cateter venoso central deinserção periférica pelo time de cateteres na incidência da Infecção da Catheter-RelatedBloodstream infection (CRBSI) em recém-nascidos na Unidade de Terapia IntensivaNeonatal. Metodologia: Esta tese está dividida em três estudos. 1) Protocolo de revisãosistemática, em que se aborda a prevalência de complicações associadas ao uso de PICCs emrecém-nascidos (RNs); 2) Coorte prospectiva, em que se avaliaram os fatores de risco para odesenvolvimento de infecção da corrente sanguínea relacionada ao cateter (CRBIS) emrecém-nascidos; 3) Coorte com análise retro e prospectiva, que analisou os efeitos dapadronização das medidas de prevenção de infecção adotadas pelo time de PICC sob onúmero de casos de CRBSI em neonatos na Unidade de Terapia Intensiva Neonatal.Resultados: No artigo 1, observou-se a prevalência de complicações decorrentes do manejoinadequado do PICC nos RNs, informação considerada importante para o aprimoramento daprática clínica. No artigo 2, verificou-se que a maioria da amostra foi composta de prematuros,com peso inadequado, distúrbios respiratórios e cardiopatia, mas não houve associação dessasvariáveis com a CRBSI. Neonatos com PICC nos membros superiores apresentaram maiorrisco de CRBSI (RR=2,84; IC95% 1,02-6,85). No artigo 3, analisaram-se 365 recémnascidos que usaram o PICC e que foram submetidos a 563 procedimentos de inserção decateteres, dos quais 69 apresentaram CRBSI, o que confere uma incidência de CRBSI de12,3%. Na análise das características relacionadas ao procedimento de inserção do PICC nosneonatos em função da notificação de CRBSI, as variáveis significativamente associadas àocorrência de CRBSI foram o vaso acessado (p=0,002) e a posição do cateter(p=0,005). Naanálise estatística das variáveis relacionadas à terapêutica infusional, observou-sesignificância estatística na associação entre a ocorrência da CRBSI e o uso de dois ATBdurante o primeiro esquema de antibioticoterapia, o qual apresentou o valor de p<0,05. 7Efeito da padronização das medidas de prevenção de infecção da corrente sanguíneaTambém se constatou que foram descritos oito grupos de patógenos envolvidos nos 69 casosde CRBSI - os mais comuns foram relacionados à CRBSI em recém-nascidos com PICC,como as Enterobactérias (5,2%), Staphylococcus coagulase negativa(3,4%) eStaphylococcus coagulase positiva (2,0%). Conclusão: O estudo indicou que os times decateteres são importantes nas unidades de terapia intensiva neonatais, sobretudo quandoadotam condutas baseadas em evidências científicas que fundamentam a sistematização doprocesso de trabalho para o devido monitoramento dos fatores de risco relacionados àincidência de CRBSI em RN, a vigilância durante realização do procedimento e a terapêuticainfusional. Contudo, o efeito da padronização das medidas de prevenção adotadas pelotime de cateteres na UTIN tem impactado a redução do desenvolvimento de infecção dacorrente sanguínea relacionada ao cateter (AU).

Introduction: The use of peripherally inserted central catheter in neonatology hassignificantly contributed to the reduction of neonatal mortality in neonatal intensive care units.It is safe intravenous practice favors the hemodynamic stabilization of the newborn, allowsthe administration of vesicant drugs, irritants and parenteral nutrition. Therefore, this studyhas as main objective to analyze the effect of the standardization of infection preventionmeasures during the insertion and handling of the peripherally inserted central venouscatheter by the catheter team on the incidence of CRBSI in newborns in the NeonatalIntensive Care Unit. Methodology: The thesis is divided into three studies. 1) Systematicreview protocol, which addresses the prevalence of complications associated with the use ofPICCs in newborns (NBs); 2) prospective cohort that evaluated risk factors for thedevelopment of catheter-related bloodstream infection (CRBIS) in newborns; 3) cohort withretro and prospective analysis, which analyzed the effect of the standardization of infectionprevention measures adopted by the PICC team on the number of CRBSI cases in neonates inthe Neonatal Intensive Care Unit. Results: in article 1 it was observed the prevalence ofcomplications resulting from inadequate management of the PICC in NBs, informationconsidered important for the improvement of clinical practice. In article 2, it was found thatthe majority of the sample was composed of premature infants, with inadequate weight,respiratory disorders and heart disease, but there was no association of these variables withthe CRBSI. Neonates with PICC in the upper limbs had a higher risk of CRBSI(RR=2.84;95%CI 1.02-6.85). At article 3 analyzed 365 newborns who used the PICC, who underwent563 catheter insertion procedures, of which 69 had CRBSI, giving an incidence of CRBSI of12.3%. In the analysis of the characteristics related to the PICC insertion procedure inneonates due to the CRBSI notification, the variables significantly associated with theoccurrence of CRBSI were the vessel accessed (p=0.002) and catheter position(p=0.005). Inthe statistical analysis of the variables related to infusion therapy, a statistical significance wasobserved in the association between the occurrence of CRBSI and the use of two ATBduring the first antibiotic therapy regimen, which presented a value of p<0.05. There wasalso a description of 8 groups of pathogens involved in the 69 cases of CRBSI, the most 9Efeito da padronização das medidas de prevenção de infecção da corrente sanguíneacommon pathogens related to CRBSI in newborns with PICC being Enterobacteriaceae(5.2%), coagulase-negative Staphylococcus (3.4%) and Coagulase positive Staphylococcus(2.0%). Conclusion: it was observed In the statistical analysis of the variables related toinfusion therapy, especially when they adopt procedures based on scientific evidence, whichunderlie thesystematization of the work process for the proper monitoring of risk factorsrelated to the incidence of CRBSI in newborns, surveillance during the procedure, andinfusion therapy. However, it is observed that effect of standardization of preventionmeasures adopted by the catheter team in the UTIN have had an impact on thereduction of development of cateter related bloodstream infection (AU).

Anterograde and Retrograde Approach With Through-and-Through Wiring Technique to Treat a Ruptured and Extremely Tortuous Giant Popoliteal Artery Aneurism.

PURPOSE: This technical note aims to show a challenging endovascular treatment approach of a giant and tortuous ruptured popliteal artery aneurism. MATERIALS AND METHODS: An 86-year-old male patient was admitted for acute lower right limb ischemia. Angio-MSCT showed highly calcified superficial femoral artery, with a 180° bend in distal portion, followed by a large popliteal aneurism (63 × 61 mm) with a large extent hematoma (142 × 112 × 104 mm). Endovascular approach was chosen due to high morbidity. RESULTS: Anterior puncture of right superficial femoral artery was performed under ultrasound guidance. Despite various intents, the 0.035 hydrophilic coated wire could not be crossed distally through the aneurism. Retrograde access was performed via tibio-peroneal trunk under fluoroscopic guidance with a micropuncture set. A stiff 0.035″ Glidewire® was successfully advanced into the proximal portion of the aneurism through a 5F vertebral catheter externalized with a snare from the femoral sheath obtaining a "through-and-through wire" technique. Tightening of both ends of the wire helped gain support and straightened curves. Two stent grafts were implanted with no residual leak at 1 month follow-up. CONCLUSION: Anterograde and retrograde approach was useful to perform a through-and-through wire technique in a challenging case of a tortuous ruptured popliteal artery aneurism.

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.

Alternative vascular device for high-flow computed tomography angiography: ultrasound-guided long peripheral catheter (4 Fr × 10 cm).

INTRODUCTION: Radiological studies that require contrast media are common and useful in the emergency department. Alternatives have been proposed for the administration of contrast agent in patients with difficulty in the insertion of vascular access. Since 2017, our institution has used a 4-Fr × 10-cm-long peripheral catheter (Leadercath; Vygon) for venous insertion. Its ultrasound-guided insertion is carried out by emergency physicians. So far, there are no reports in the literature about the use of this long peripheral catheter for computed tomography angiography. OBJECTIVE: To describe the experience with the said device, to point out the complications associated with it, and to evaluate it as an alternative way to gain vascular access for patients with limited venous access. METHODS: An observational, analytical, and retrospective study was conducted. The study included patients who received an ultrasound-guided 4-Fr × 10-cm-long peripheral catheter (Leadercath; Vygon). Transparent, radiopaque, polyethylene, 18-gauge Leadercath from Vygon, sold as peripheral arterial catheter and sometimes used "off-label" as venous catheter with a flow capacity of up to 24 mL/min, was used. The flow capacity for gravity flow is 24 mL/s; with pump-driven flow, we achieved a flow infusion of 5-6 mL/s. Univariate analyses were performed. Normality was determined through the Shapiro-Wilk test. RESULTS: In total, 172 patients met the inclusion criteria. Of them, 115 (67%) were female and the average age was 59 years. The main indication for performing the computed tomography angiography was the suspicion of pulmonary embolism (38.6%). The most frequent type of computed tomography angiography study was pulmonary tomography (88 patients, 51.5%). The contrast medium infusion rate was 6 mL/s in 51.5% (n = 88) of cases, 4.5 mL/s in 36.3%, and 5 mL/s in 12.3%. One adverse event occurred. CONCLUSION: An 18-gauge-long peripheral catheter (4 Fr × 10 cm, Leadercath; Vygon) following specific protocols appears to be safe for conducting high-flow computed tomography studies in patients with limited venous access.

Intrapartum epidural catheter displacement: Comparison of three dressing methods (Migración de catéter epidural intraparto: Comparación de tres métodos de fijación).

AIM: To compare the effect on epidural catheter migration of three different types of dressing used in labor. INTRODUCTION: Failure of labor epidural is due to multiple factors including catheter migration. Epidural catheter migration has been showed to be related to body mass index and patient position. The dressing technique also influences catheter migration and the risk of epidural failure. METHODS: Patients were randomly allocated to one of three groups based on type of dressing of labor epidural: TegadermTM (Group T), TegadermTM with sticky pad (Group P), and TegadermTM with Steri-StripTM (Group S). Measured variables included parity, gestational age, body mass index (BMI), level of puncture and distance of epidural catheter migration. RESULTS: There was an overall difference in epidural catheter migration (ECM) distance among different groups (p<0.05). Pairwise comparison revealed only a significant difference between groups P and T (0.76±1.35 vs. -0.14±1.03, p<0.01). CONCLUSION: Taping the lumbar epidural catheter used for labor analgesia with TegadermTM is inferior to TegadermTM with sticky pad or with Steri-StripTM in terms of catheter migration. There is no association of catheter migration and BMI.

Objetivo: Comparar el efecto de tres diferentes tipos de fijación sobre la migración del catéter epidural durante el trabajo de parto. Introducción: El fallo del bloqueo epidural en el trabajo de parto se debe a múltiples factores incluyendo la migración de catéter. La migración de catéter epidural se ha relacionado con el índice de masa corporal y la posición, así como con movimientos del paciente. La técnica de fijación también afecta la migración de catéter y el riesgo de bloqueo epidural fallido. Método: Las pacientes fueron aleatorizadas y asignadas a uno de tres grupos según el tipo de fijación: TegadermTM (Grupo T), TegadermTM con almohadilla adhesiva (Grupo P) y Tegaderm TM con Steri-StripTM (Grupo S). Las variables evaluadas incluyeron paridad, edad gestacional, índice de masa corporal (IMC), nivel de punción y distancia de migración del catéter epidural. Resultados: Se detectó una diferencia en la distancia de migración de catéter epidural entre los diferentes grupos (p<0.05). La comparación reveló diferencia únicamente entre los grupos P y T (0.76±1.35 vs. -0.14±1.03, p<0.01). Conclusión: TegadermTM como método de fijación de catéter epidural en el trabajo de parto resultó ser inferior al TegadermTM con almohadilla adhesiva o con Steri-StripTM en términos de migración de catéter. No existe una asociación entre migración de catéter epidural e IMC.

Preventive risk analysis in the maintenance of patency of the peripherally inserted central catheter.

This theoretical and reflexive study analyzed the risks related to the maintenance of patency of the Peripherally Inserted Central Catheter with the use of saline solution in comparison with saline-filled syringes, through the application of the Healthcare Failure Mode and Effect Analysis - HFMEA. The process was mapped, detailing the failure modes of each step. For the calculation of the Risk Priority Number, the severity and probability of the failure modes were analyzed. This analysis gave rise to the severity and probability matrix. Finally, actions to reduce the failure modes in the maintenance of patency were proposed, considering the use of saline-filled syringes in comparison to the use of saline ampoules. It was verified that the use of saline ampoules is associated with a greater risk, since it requires four stages more than saline-filled syringe does not, increasing the risk of contamination and the level of three different risks, which would result in additional hospital costs. The use of the saline-filled syringe would avoid risks that could negatively affect the patient's health, the nursing professional and the health institution.

Increased Risk of Thrombosis Associated with Peripherally Inserted Central Catheters Compared with Conventional Central Venous Catheters in Children with Leukemia.

OBJECTIVE: To study the risk of catheter-associated thrombosis (CAT) between peripherally inserted central catheters (PICCs) and tunneled central venous catheters in children with leukemia. STUDY DESIGN: We analyzed all PICCs and conventional tunneled catheters placed in patients aged <18 years and admitted to our institute for leukemia treatment between February 2008 and April 2014. Cases of symptomatic CAT were confirmed by ultrasound and treated with low-molecular-weight heparin. RESULTS: During the study period, 157 PICCs and 138 conventional tunneled catheters were placed in 192 patients with leukemia. CAT incidence was 1.5% (n = 2) in the conventional tunneled catheter group and 10.2% (n = 16) in the PICC group. The OR for CAT occurrence after PICC vs conventional tunneled catheter placement was 5.6 (95% CI, 1.2-26.5). CONCLUSION: Our results suggest that the use of PICCs in children with leukemia increases the risk of CAT in comparison with the use of conventional tunneled catheters. Further randomized controlled studies are needed to characterize this risk and to better define indications.

"Snare-Ride": A Bailout Technique to Catheterize Target Vessels With Unfriendly Anatomy in Branched Endovascular Aortic Repair.

PURPOSE: To describe a novel endovascular bailout technique for successful completion of target vessel stenting during branched stent-graft repair of thoracoabdominal aortic aneurysms (TAAA) after encountering difficulties with standard catheterization techniques. TECHNIQUE: Technical difficulties when using fenestrated and branched grafts should be expected, especially in difficult anatomy or when an off-the-shelf device (eg, standard 4-branch device) is used that does not perfectly "match" the anatomy. The "snare-ride technique" facilitates antegrade transaxillary side branch catheterization and stent placement during TAAA branched grafting using a snare via a transfemoral approach. The branch of the graft is catheterized from an axillary access. The respective target vessel is then catheterized via a femoral access. An Indy snare is advanced over the transfemoral wire and positioned near the entrance of the target vessel. The transaxillary wire inside the branch of the graft is then advanced, snared, and pushed inside the target vessel with the snare. The procedure is thereafter continued with antegrade bridging of the target vessel in routine fashion. CONCLUSION: The snare-ride technique can be a useful maneuver to catheterize target vessels with difficult anatomy in TAAA branched stent-graft repair. Early experience shows safety and feasibility.

Arterial protocol including prophylactic distal perfusion catheter decreases limb ischemia complications in patients undergoing extracorporeal membrane oxygenation.

OBJECTIVE: Venoarterial extracorporeal membrane oxygenation (ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Owing to the large size of the cannulas inserted via the femoral vessels (≤24-F) required for adequate oxygenation, this procedure could result in significant limb ischemic complications (10%-70%). This study evaluates the results of a distal limb perfusion arterial protocol designed to reduce associated complications. METHODS: We conducted a retrospective institutional review board-approved review of consecutive patients requiring ECMO via femoral cannulation (July 2010-January 2015). To prevent arterial ischemia, a distal perfusion catheter (DPC) was placed antegrade into the superficial femoral artery and connected to the ECMO circuit. Limb perfusion was monitored via near-infrared spectroscopy (NIRS) placed on both calves. Decannulation involved open repair, patch angioplasty, and femoral thrombectomy as needed. RESULTS: A total of 91 patients were placed on ECMO via femoral arterial cannula (16-F to 24-F) for a mean duration of 9 days (range, 1-40 days). A percutaneous DPC was inserted prophylactically at the time of cannulation in 55 of 91 patients, without subsequent ischemia. Of the remaining 36 patients without initial DPC placement, 12 (33% without DPC) developed ipsilateral limb ischemia related to arterial insufficiency, as detected by NIRS and clinical findings. In these patients, the placement of a DPC (n = 7) with or without a fasciotomy, or with a fasciotomy alone (n = 4), resulted in limb salvage; only one patient required subsequent amputation. After decannulation (n = 7), no patients had further evidence of limb ischemia. Risk factors for the development of limb ischemia identified by categorical analysis included lack of DPC at time of cannulation and ECMO cannula size of less than 20-Fr. There was a trend toward younger patient age. Overall ECMO survival rate was 42%, whereas survival in patients with limb ischemia was only 25%. CONCLUSIONS: Limb ischemia complications from ECMO may be decreased by prophylactic placement of an antegrade DPC. Without DPC, continuous monitoring using NIRS may identify limb ischemia, which can be treated subsequently with DPC and or fasciotomy.

Transradial Versus Transfemoral Carotid Artery Stenting: A 16-Year Single-Center Experience.

AIMS: Limited data exist on radial access in carotid artery stenting (CAS). This single-center study was performed to compare the outcome and complication rates of transradial (TR) and transfemoral (TF) CAS. METHODS AND RESULTS: The clinical and angiographic data of 775 consecutive patients with high risk for carotid endarterectomy, treated between 1999 and 2016 by CAS with cerebral protection, were evaluated. Patients were divided into 2 groups according to vascular access: TR (n = 101; 13%) and TF (n = 674). Primary combined end-point: in-hospital major adverse cardiac and cerebral events. Secondary end-points: angiographic outcome of the procedure and crossover rate to another puncture site. Angiographic success was achieved in all 775 patients, the crossover rate was 4.9% in the TR and 0% in the TF group (P < 0.05). TR was performed at the right side in 97% of cases. The incidence of in-hospital major adverse cardiac and cerebral events was 2% in the TR and 3.6% in the TF group (P = ns). CONCLUSIONS: The TR approach for CAS is safe and efficacious, with acceptable cross-over rate. In both groups, vascular complications rarely occurred.

Incidence of phlebitis associated with the use of peripheral IV catheter and following catheter removal.

OBJECTIVE: to investigate the incidence of phlebitis and its association with risk factors when using peripheral IV catheters (PIC) and following their removal - (post-infusion phlebitis) in hospitalized adults. METHOD: a cohort study of 171 patients using PIC, totaling 361 punctures. Sociodemographic variables and variables associated with the catheter were collected. Descriptive and analytical statistical analyses were performed. RESULTS: average patient age was 56.96 and 51.5% of the sample population was male. The incidence of phlebitis was 1.25% while using PIC, and 1.38% post-infusion. The incidence of phlebitis while using PIC was associated with the length of time the catheter remained in place, whereas post-infusion phlebitis was associated with puncture in the forearm. Ceftriaxone, Clarithromycin and Oxacillin are associated with post-infusion phlebitis. CONCLUSIONS: this study made it possible to investigate the association between risk factors and phlebitis during catheter use and following its removal. The frequency of post-infusion phlebitis was larger than the incidence of phlebitis with the catheter in place, with Phlebitis Grade III and II being the most frequently found in each of these situations, respectively. Aspects related to post-infusion phlebitis can be explained, given the limited number of studies addressing this theme from this perspective. OBJETIVO: investigar a incidência de flebites e a associação de fatores de risco com a sua ocorrência durante o uso e após a retirada do cateter intravenoso periférico - CIP (Flebite pós-infusão) em adultos hospitalizados. MÉTODO: estudo de coorte com 171 pacientes com CIP, totalizando 361 punções. Foram coletadas variáveis sociodemográficas e relacionadas ao cateter. Análise estatística descritiva e analítica. RESULTADOS: dos pacientes, 51,5% eram homens e a média de idade foi de 56,96 anos. A incidência de flebites durante o uso do CIP foi de 1,25% e a pós-infusão foi de 1,38%. Associou-se à flebite durante o uso do CIP ao tempo de permanência do cateter e, com a flebite pós-infusão, a punção em antebraço. Os medicamentos Ceftriaxona, Claritromicina e Oxacilina foram associados à flebite pós-infusão. CONCLUSÕES: este estudo possibilitou investigar a associação de fatores de risco e a ocorrência de flebites durante o uso e após a retirada do cateter. A frequência da flebite pós-infusão foi maior do que o número de flebites durante a permanência do cateter, sendo as de grau III e II, respectivamente, as mais frequentes. Podem ser elucidados aspectos relacionados à flebite pós-infusão, considerando-se poucos estudos abordam o tema sob esta perspectiva. OBJETIVO: investigar la incidencia de flebitis y la asociación de factores de riesgo con su ocurrencia durante el uso y después de la retirada del catéter intravenoso periférico (CIP) (flebitis post-infusión) en adultos hospitalizados. MÉTODO: estudio de cohorte con 171 pacientes con CIP, totalizando 361 punciones. Fueron recolectadas variables sociodemográficas y relacionadas al catéter. Análisis estadístico descriptivo y analítico. RESULTADOS: de los pacientes, 51,5% eran hombres y el promedio de edad fue de 56,96 años. La incidencia de flebitis durante el uso del CIP fue de 1,25% y de post-infusión fue de 1,38%. Se asoció la flebitis durante el uso del CIP al tiempo de permanencia del catéter y con la post-infusión (punción en el antebrazo). Los medicamentos Ceftriaxona, Claritromicina y Oxacilina fueron asociados a la flebitis post-infusión. CONCLUSIONES: este estudio posibilitó investigar la asociación de factores de riesgo y la ocurrencia de flebitis durante el uso y después de la retirada del catéter. La frecuencia de la flebitis post-infusión fue mayor que el número de flebitis asociada a la permanencia del catéter, siendo las de grado III y II, respectivamente, las más frecuentes. Se trato de elucidar aspectos relacionados a la flebitis post-infusión, considerando que existen pocos estudios que abordan el tema bajo esta perspectiva.

Incidence of phlebitis associated with the use of peripheral IV catheter and following catheter removal / Incidência de flebites durante o uso e após a retirada de cateter intravenoso periférico / Incidencia de flebitis durante el uso y después de la retirada de catéter intravenoso periférico

ABSTRACT Objective: to investigate the incidence of phlebitis and its association with risk factors when using peripheral IV catheters (PIC) and following their removal - (post-infusion phlebitis) in hospitalized adults. Method: a cohort study of 171 patients using PIC, totaling 361 punctures. Sociodemographic variables and variables associated with the catheter were collected. Descriptive and analytical statistical analyses were performed. Results: average patient age was 56.96 and 51.5% of the sample population was male. The incidence of phlebitis was 1.25% while using PIC, and 1.38% post-infusion. The incidence of phlebitis while using PIC was associated with the length of time the catheter remained in place, whereas post-infusion phlebitis was associated with puncture in the forearm. Ceftriaxone, Clarithromycin and Oxacillin are associated with post-infusion phlebitis. Conclusions: this study made it possible to investigate the association between risk factors and phlebitis during catheter use and following its removal. The frequency of post-infusion phlebitis was larger than the incidence of phlebitis with the catheter in place, with Phlebitis Grade III and II being the most frequently found in each of these situations, respectively. Aspects related to post-infusion phlebitis can be explained, given the limited number of studies addressing this theme from this perspective.

RESUMO Objetivo: investigar a incidência de flebites e a associação de fatores de risco com a sua ocorrência durante o uso e após a retirada do cateter intravenoso periférico - CIP (Flebite pós-infusão) em adultos hospitalizados. Método: estudo de coorte com 171 pacientes com CIP, totalizando 361 punções. Foram coletadas variáveis sociodemográficas e relacionadas ao cateter. Análise estatística descritiva e analítica. Resultados: dos pacientes, 51,5% eram homens e a média de idade foi de 56,96 anos. A incidência de flebites durante o uso do CIP foi de 1,25% e a pós-infusão foi de 1,38%. Associou-se à flebite durante o uso do CIP ao tempo de permanência do cateter e, com a flebite pós-infusão, a punção em antebraço. Os medicamentos Ceftriaxona, Claritromicina e Oxacilina foram associados à flebite pós-infusão. Conclusões: este estudo possibilitou investigar a associação de fatores de risco e a ocorrência de flebites durante o uso e após a retirada do cateter. A frequência da flebite pós-infusão foi maior do que o número de flebites durante a permanência do cateter, sendo as de grau III e II, respectivamente, as mais frequentes. Podem ser elucidados aspectos relacionados à flebite pós-infusão, considerando-se poucos estudos abordam o tema sob esta perspectiva.

RESUMEN Objetivo: investigar la incidencia de flebitis y la asociación de factores de riesgo con su ocurrencia durante el uso y después de la retirada del catéter intravenoso periférico (CIP) (flebitis post-infusión) en adultos hospitalizados. Método: estudio de cohorte con 171 pacientes con CIP, totalizando 361 punciones. Fueron recolectadas variables sociodemográficas y relacionadas al catéter. Análisis estadístico descriptivo y analítico. Resultados: de los pacientes, 51,5% eran hombres y el promedio de edad fue de 56,96 años. La incidencia de flebitis durante el uso del CIP fue de 1,25% y de post-infusión fue de 1,38%. Se asoció la flebitis durante el uso del CIP al tiempo de permanencia del catéter y con la post-infusión (punción en el antebrazo). Los medicamentos Ceftriaxona, Claritromicina y Oxacilina fueron asociados a la flebitis post-infusión. Conclusiones: este estudio posibilitó investigar la asociación de factores de riesgo y la ocurrencia de flebitis durante el uso y después de la retirada del catéter. La frecuencia de la flebitis post-infusión fue mayor que el número de flebitis asociada a la permanencia del catéter, siendo las de grado III y II, respectivamente, las más frecuentes. Se trato de elucidar aspectos relacionados a la flebitis post-infusión, considerando que existen pocos estudios que abordan el tema bajo esta perspectiva.

[Incidence of adverse events associated to the use of short peripheral venous catheters]. / Incidencia de eventos secundarios asociados al uso de catéteres cortos venosos periféricos.

BACKGROUND: Surveillance of adverse events associated to the use of short peripheral venous catheters (SPVC) is an indicator of quality of service. The objective was to report the incidence and risk factors associated to adverse events in SPVC. METHODS: Prospective cohort study. All patients with a SPVC for more than 48 hours were included. The outcome variables were dysfunction, chemical phlebitis and bacterial phlebitis. The data registered were age, sex, underlying diseases, nutritional status, site of placement, skin condition, administered intravenous fluids, and catheter dressing. Regarding statistical analysis, incidence rate for each adverse event was calculated per 100 catheters and per 1000 catheter-days. Univariate and multivariate analysis of risk factors were performed. RESULTS: 410 catheters were analyzed. Median of SPVC use was of three days. There was no evidence of infectious complications: 47 (11.4 %) presented chemical phlebitis and 231 (56.3 %) mechanical malfunction; the incidence rate was 35.6 and 175 per 1000 catheter-days, respectively. In the multivariate analysis, the risk factors associated to chemical phlebitis were skin lesions (p = 0.001, RR 3.479), and additional dressing use (p = 0.007, RR 4.025); for mechanical malfunction the only risk factor was the administration of intravenous chemotherapy (p = 0.026, RR 4.293). CONCLUSIONS: The malfunction incidence rate was high; in consequence, the catheter was removed before 96 hours of use. This could explain the absence of infectious complications.

Introducción: la vigilancia de los eventos secundarios al uso de catéteres venosos periféricos es un indicador de calidad de la atención. El objetivo del estudio fue reportar la incidencia y los factores de riesgo para eventos adversos asociados a catéteres cortos periféricos. Métodos: estudio de cohorte prospectiva. Se incluyeron pacientes que tuvieron catéter corto periférico por más de 48 horas. Las variables de resultado fueron la disfunción y la flebitis química o bacteriana. Se registró edad, sexo, enfermedad de base, estado nutricional, sitio y lugar de colocación, calidad de la piel, tipo de soluciones administradas y fijación. En cuanto al análisis estadístico, se calculó la incidencia de los eventos adversos por 100 catéteres y por 1000 días catéter; se realizó análisis univariado y multivariado de los factores de riesgo. Resultados: se incluyeron 410 catéteres, con una mediana de días de uso de tres días. No hubo complicaciones infecciosas: 47 presentaron flebitis química (11.4 %) y 231 disfunción mecánica (56.3 %), la densidad de incidencia fue de 35.6 y 175 por 1000 días catéter respectivamente. En el análisis multivariado los factores asociados con flebitis química fueron lesiones en piel (p = 0.001, RR 3.479), y uso de recubrimiento extra (p = 0.007, RR 4.025); para disfunción mecánica fue administración de quimioterapia (p = 0.026, RR 4.293). Conclusión: la tasa de disfunción fue elevada, lo que lleva a retiro del catéter antes de las 96 horas. No se registraron complicaciones infecciosas.

Catheter-directed interventions for acute pulmonary embolism.

Acute pulmonary embolism (PE) is a leading cause of cardiovascular mortality. Systemic anticoagulation is the standard of care, and treatment can be escalated in the setting of massive or submassive PE, given the high mortality risk. A secondary consideration for intervention is the prevention of late-onset chronic thromboembolic pulmonary hypertension. Treatment options include systemic thrombolysis, catheter-directed interventions, and surgical thromboembolectomy. Whereas systemic thrombolysis seems to be beneficial in the setting of massive PE, it appears to be associated with a higher rate of major complications compared with catheter-directed thrombolysis as shown in recent randomized trials for submassive PE. The hemodynamic and clinical outcomes continue to be defined to determine the indications for and benefits of intervention. The current review summarizes contemporary evidence on the role and outcomes of catheter-directed therapies in the treatment of acute massive and submassive PE.

The establishment and evaluation of rabbit model for peripherally inserted central catheter.

PURPOSE: To establish a model to simulate the clinical specific process of peripherally inserted central catheter (PICC) on rabbits, and detect how long the catheter can be indwelled. METHODS: Seventeen healthy New Zealand white rabbits were inserted the PICC according to the clinical specific procedure. With the principle of random, the rabbits were divided into four groups (14d, 21d, 28d, 35d). Each group contains four rabbits, and Group 1 was served as blank control group. When finishing the experiment, we took the blood vessels which was inserted the catheter and observed the changes of vascular endothelium using the Hematoxylin-Eosin (HE) staining. RESULTS: 90% animals were succeeded in inserting PICC. Early signs of endovascular inflammation were predominantly neutrophils, then mainly monocytes, visible fibrous tissue hyperplasia of the vessel wall, vascular endothelial proliferation and granuloma formation. And after that the irreversible changes in the blood vessels could be observed, especially five weeks after catheterization. CONCLUSIONS: We have succeeded in establishing the rabbit model for peripherally inserted central catheter, and provided a new way for nursing teaching and training. Since the irreversible changes of the vascular endothelium, it is recommended that the time of indwelling is not more than five weeks on animal.

The establishment and evaluation of rabbit model for peripherally inserted central catheter

PURPOSE: To establish a model to simulate the clinical specific process of peripherally inserted central catheter (PICC) on rabbits, and detect how long the catheter can be indwelled. METHODS: Seventeen healthy New Zealand white rabbits were inserted the PICC according to the clinical specific procedure. With the principle of random, the rabbits were divided into four groups (14d, 21d, 28d, 35d). Each group contains four rabbits, and Group 1 was served as blank control group. When finishing the experiment, we took the blood vessels which was inserted the catheter and observed the changes of vascular endothelium using the Hematoxylin-Eosin (HE) staining. RESULTS: 90% animals were succeeded in inserting PICC. Early signs of endovascular inflammation were predominantly neutrophils, then mainly monocytes, visible fibrous tissue hyperplasia of the vessel wall, vascular endothelial proliferation and granuloma formation. And after that the irreversible changes in the blood vessels could be observed, especially five weeks after catheterization. CONCLUSIONS: We have succeeded in establishing the rabbit model for peripherally inserted central catheter, and provided a new way for nursing teaching and training. Since the irreversible changes of the vascular endothelium, it is recommended that the time of indwelling is not more than five weeks on animal. .