The safety of early versus late ambulation in the management of patients after percutaneous coronary interventions: A meta-analysis

Bed rest duration and complications after transfemoral cardiac catheterization: a network meta-analysis

AIM

To assess the effects of bed rest duration on short-term complications following transfemoral catheterization.

METHODS & RESULTS

A systematic search was carried out in MEDLINE, Embase, CINAHL, Cochrane Database of Systematic Reviews, Scopus, SciELO, and in five registries of grey literature. Randomized controlled trials and quasi-experimental studies comparing different duration of bed rest after transfemoral catheterization were included. Primary outcomes were hematoma and bleeding near the access site. Secondary outcomes were arteriovenous fistula, pseudoaneurysm, back pain, general patient discomfort and urinary discomfort. Study findings were summarized using a network meta-analysis (NMA).Twenty-eight studies and 9217 participants were included (mean age 60.4 years). In NMA, bed rest duration was not consistently associated with either primary outcome, and this was confirmed in sensitivity analyses. There was no evidence of associations with secondary outcomes, except for two effects related to back pain. A bed rest duration of 2-2.9 hours was associated with lower risk of back pain (RR 0.33, 95%CI 0.17-0.62), and a duration over 12 hours with greater risk of back pain (RR 1.94, 95%CI 1.16-3.24), when compared to the 4-5.9 hours interval. Post-hoc analysis revealed an increased risk of back pain per hour of bed rest (RR 1.08, 95%CI 1.04-1.11).

CONCLUSIONS

A short bed rest was not associated with complications in patients undergoing transfemoral catheterization; the greater the duration of bed rest, the more likely patients were to experience back pain. Ambulation as early as 2 hours after transfemoral catheterization can be safely implemented.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero. Identifier: PROSPERO CRD42014014222.

Is It Safe to Mobilize Patients Very Early After Transfemoral Coronary Procedures? (SAMOVAR): A Randomized Clinical Trial

BACKGROUND

Coronary angiography (CAG) and percutaneous coronary intervention (PCI) are performed via the femoral or radial arteries. In patients examined via transfemoral access, closure devices facilitate hemostasis, but it is unknown whether it is safe to mobilize these patients immediately and how acceptable this may be in terms of patient comfort.

OBJECTIVE

The aims of this study were to investigate bleeding complications in patients mobilized immediately after transfemoral CAG or PCI compared with patients on bed rest (BR) for 2 hours after the procedure and, furthermore, to investigate patient comfort in relation to mobilization and BR.

METHODS

SAMOVAR was a noninferiority trial with patients randomized to immediate mobilization (IM) or 2 hours of BR after transfemoral CAG or PCI and use of the AngioSeal as a closure device and reversal of heparin effect. The primary end point was development of hematoma greater than 5 cm, pseudoaneurysm, or bleeding requiring blood transfusion. Secondary end points were oozing from the puncture site, small hematoma, and patient comfort.

RESULTS

Of 2027 patients (IM, 1010; BR, 1017), 40% underwent PCI. The primary outcome was recorded in 0.7% patients randomized to IM versus 0.5% in BR (P = .58). There was no difference in the incidence of small hematoma, whereas persistent oozing was seen slightly more often after IM compared with BR (12% vs 9%, P = .04). Patients mobilized immediately reported less back pain and micturition problems (P < .001).

CONCLUSIONS

In patients who had CAG and PCI performed through transfemoral access, reversal of anticoagulation and use of closure devices allowed IM with low rates of complications and improved patient comfort.

Publication and related bias in quantitative health services and delivery research: a multimethod study

Background

Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.

Objectives

To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.

Methods

The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).

Results

We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.

Conclusions

This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.

Study registration

This study is registered as PROSPERO CRD42016052333 and CRD42016052366.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.

Recommendations for Endovascular Care of Stroke Patients

The field of neurointerventional radiology (NIR) therapy, including acute ischemic stroke intervention, endovascular intracranial aneurysm management, and treatment of intra- and extracranial large-vessel disease, has evolved over the past 18 years. To support this specialized advanced care requires nursing standards of care for staff to provide direct patient care in NIR suites and intensive management of this high-risk patient population. The intent of this paper is to provide a complementary document for the Stroke Interventional Laboratory Consensus (SILC) statement that will specifically address the nursing standards of care for patients in an NIR suite.

A Modified Supine Position Facilitates Bladder Function in Patients Undergoing Percutaneous Coronary Intervention: A Randomized Controlled Clinical Trial

BACKGROUND

Percutaneous coronary intervention (PCI) is currently the most common intervention for cardiovascular disease. Standard care after PCI typically involves a period of bed rest in the supine position, but this position creates voiding difficulties.

OBJECTIVE

This study aimed to determine whether a modified supine position could facilitate bladder emptying after PCI.

METHOD

A randomized controlled trial involving 300 patients was conducted. Patients in the intervention group were nursed in the supine position with the bed tilted 20° upright and with a pillow between their feet and the end of the bed. Patients in the control group received standard care, which was supine positioning.

RESULTS

One hundred fifty patients were allocated to the intervention group (100 men, 50 women), and 150 were allocated to the control group (103 men, 47 women). Baseline data did not differ between the 2 groups. Patients in the intervention group had significantly better bladder function as evidenced by a shorter time to the first void (5 vs 15 minutes) and fewer patients requiring voiding assistance (8.6% vs 35.3%). Residual urinary volumes were also much lower in the intervention group (88.71 vs 248.22 mL, P < .001).

CONCLUSIONS

This study demonstrates that a modified supine position can reduce the incidence of impaired micturition and the preservation of normal bladder function after PCI.

Decreased bed rest post-percutaneous coronary intervention with a 7-French arterial sheath and its effects on vascular complications

AIMS AND OBJECTIVES

To compare the incidence of femoral access puncture site complications in the control group, who underwent 6 hr of bed rest, with patients in the case group, who underwent 4 hr of bed rest.

BACKGROUND

The ideal bed rest length after percutaneous coronary intervention with a 7-French arterial sheath has been investigated by nursing practice. However, in this larger-sheath-size group, best practices have not been determined, and bed rest time continues to vary markedly among institutions.

DESIGN

Retrospective study.

METHODS

Data were retrieved from the National Cardiovascular Data Registry and electronic health records in this retrospective study. Sample size was 401 patients: 152 case patients with 4-hr bed rest and 249 controls with 6-hr bed rest. Case group data were obtained from 20 May 2013-31 December 2014; and control group data, 15 June 2011-20 May 2013.

RESULTS

National Cardiovascular Data Registry event rates were generally low in both groups: Only three patients in each group had a bleeding event within 72 hr (2% vs. 1%) and no patient and only two controls had arteriovenous fistula (0% vs. 1%). Complications documented in the electronic health records with institutional femoral access puncture site complication definitions identified bleeding at the access site in eight case patients (5%) and nine controls (4%). Haematoma at the access site occurred in 21 case patients (14%) and 25 controls (10%).

CONCLUSIONS

The practice change of decreasing bed rest from 6-4 hr for patients with 7-French arterial sheaths post-percutaneous coronary intervention was associated with no significant change in femoral access puncture site complications in either National Cardiovascular Data Registry data or institutional electronic health records data.

RELEVANCE TO CLINICAL PRACTICE

This introduces expanded evidence of safety in decreasing bed rest length in larger (7-French) arterial sheaths post-percutaneous coronary intervention.

The safety and efficacy of high versus low vancomycin trough levels in the treatment of patients with infections caused by methicillin-resistant Staphylococcus aureus: a meta-analysis

BACKGROUND

Recent guidelines have recommended vancomycin trough levels of 15-20 mg/L for treatment of serious infections caused by methicillin-resistant Staphylococcus aureus (MRSA). However, high trough levels may increase risk of nephrotoxicity and mortality, and high vancomycin trough levels have not been well studied. This study was designed to combine safety and efficacy results from independent studies and to compare between high and low vancomycin trough levels in the treatment of MRSA-infected patients using meta-analysis.

METHODS

From 19 eligible studies, 9 studies were included in meta-analysis to compare clinical success between high and low vancomycin trough levels, while 10 and 11 studies met criteria for comparing trough levels and nephrotoxicity and trough levels and mortality, respectively. The PubMed/Medline, Web of Science, and Scopus databases, and hand searching were used to identify eligible studies dated up to March 2016. Of 2344 subjects with MRSA infection, 1036 were assigned to trough levels ≥15 mg/L and 1308 to trough levels <15 mg/L.

RESULTS

High vancomycin trough levels were found to be associated with risk of nephrotoxicity (odds ratio [OR] 2.14, 95 % confidence interval [CI] 1.42-3.23 and adjusted OR 3.33, 95 % CI 1.91-5.79). There was no evidence of difference between high and low vancomycin trough levels for mortality (OR; 1.09; 95 % CI 0.75-1.60) or clinical success (OR 1.07; 95 % CI 0.68-1.68).

CONCLUSION

In this study, high vancomycin trough levels were identified as an independent factor associated with risk of nephrotoxicity in MRSA-infected patients. Association between vancomycin trough levels and both adverse effects and clinical outcomes requires further study.

Bed rest duration after sheath removal following percutaneous coronary interventions: a systematic review and meta-analysis

AIMS AND OBJECTIVES

To explore the effect of bed rest duration after sheath removal following percutaneous coronary interventions on the incidence of vascular complications, back pain and urinary problems.

BACKGROUND

According to the literature, the duration of bed rest after sheath removal following percutaneous coronary interventions ranges from 2-24 hours. Several studies have assessed the effect of duration of bed rest on vascular complications, but a clear final conclusion about the exact duration of bed rest has not been reached.

DESIGN

Systematic review and meta-analysis.

METHODS

Cochrane Library, MEDLINE, SCOPUS, CINAHL, IranMedex and IranDoc were searched. No language limitation was applied. RCTs that used two different periods for ambulation were included. Two reviewers separately assessed the quality of each included study and extracted the data. Dichotomous outcomes were recorded as odds ratio with 95% confidence interval.

RESULTS

Five studies involving 1115 participants were included in the review. Among them, two studies had three comparison groups. The studies considered a variety of periods as early and late ambulation, ranging from 2-10 hours. Totally, there were no statistically significant differences in the incidence of bleeding, pseudoaneurysm, arteriovenous fistula and urinary problems between early and late ambulation. There was a statistically significant reduction in the risk of haematoma formation at four to six hours of bed rest compared with eight hours of bed rest (odds ratio = 0·37, 95% CI: 0·15, 0·91). Back pain was reported in one study evaluating three hours of bed rest with an odds ratio of 0·45 (95% confidence interval: 0·28, 0·71) when compared with 10 hours of bed rest.

CONCLUSIONS

Early ambulation after percutaneous coronary interventions is safe and feasible; however, the results should be used with caution as the majority of included studies had methodological flaws.

RELEVANCE TO CLINICAL PRACTICE

The results of this study suggest that patients could be ambulated three to four hours after sheath removal following percutaneous coronary interventions and early ambulation dose does not increase the risk of vascular complications, but it moderates back pain occurrence.