Chronic subdural hematoma drainage using anti-thrombotic catheter technique

Background

Burr hole evacuation is a well-established treatment for symptomatic cases with chronic subdural hematoma (cSDH). Routinely postoperative catheter is left in the subdural space to drain the residual blood. Drainage obstruction is commonly seen, and it can be related to suboptimal treatment.

Methods

Two groups of patients submitted to cSDH surgery were evaluated in a retrospective non-randomized trial, one group that had conventional subdural drainage (CD group, n ​= ​20) and another group that used an anti-thrombotic catheter (AT group, n ​= ​14). We compared the obstruction rate, amount of drainage and complications. Statistical analyses were done using SPSS (v.28.0).

Results

For AT and CD groups respectively (median ​± ​IQR), the age was 68.23 ​± ​26.0 and 70.94 ​± ​21.5 (p ​> ​0.05); preoperative hematoma width was 18.3 ​± ​11.0 ​mm and 20.7 ​± ​11.7 ​mm and midline shift was 13.0 ​± ​9.2 and 5.2 ​± ​8.0 ​mm (p ​= ​0.49). Postoperative hematoma width was 12.7 ​± ​9.2 ​mm and 10.8 ​± ​9.0 ​mm (p ​< ​0.001 intra-groups compared to preoperative) and MLS was 5.2 ​± ​8.0 ​mm and 1.5 ​± ​4.3 ​mm (p ​< ​0.05 intra-groups). There were no complications related to the procedure including infection, bleed worsening and edema. No proximal obstruction was observed on the AT, but 8/20 (40%) presented proximal obstruction on the CD group (p ​= ​0.006). Daily drainage rates and length of drainage were higher in AT compared to CD: 4.0 ​± ​1.25 days vs. 3.0 ​± ​1.0 days (p ​< ​0.001) and 69.86 ​± ​106.54 vs. 35.00 ​± ​59.67 ​mL/day (p ​= ​0.074). Symptomatic recurrence demanding surgery occurred in two patients of CD group (10%) and none in AT group (p ​= ​0.230), after adjusting for MMA embolization, there was still no difference between groups (p ​= ​0.121).

Conclusion

The anti-thrombotic catheter for cSDH drainage presented significant less proximal obstruction than the conventional one and higher daily drainage rates. Both methods demonstrated to safe and effective for draining cSDH.

Central venous access device locking practices in the adult critical care setting: a single-centre, observational study establishing duration of locking per catheter lumen

PURPOSE

Central line complications remain a problem in critical care patient populations. Various interventions to prevent or treat complications, such as central line-associated bloodstream infection and occlusion, have been the focus of recent research. Although alternative catheter locking solutions have been shown to be effective in other patient populations, their applicability to the critical care setting remains unclear. Due to the high acuity of critical care patients, it is uncertain whether their central lines remain locked for a duration long enough for alternative locking solutions to provide any effect.

METHODS

This single-centre, prospective, observational study aimed to gather information about the length of time central line lumens remain in a locked state in the average critical care patient. Baseline rates of various central line complications were also tracked.

RESULTS

Results of this study indicate that the majority of central lines will have at least one lumen locked for an average of 36.6% of their time in situ.

CONCLUSIONS

It is anticipated that this length of time provides enough exposure for alternative locking solutions to potentially make a difference in central line complications in this patient population. Results of this study can be used for planning future multi-centre, randomized controlled trials investigating the efficacy of novel central line locking solutions to prevent central line complications in critically ill patients.

Sternal Retraction and Subclavian Vein Catheter Occlusion during Cardiac Surgery

Background

Subclavian vein (SV) catheterization is a method for the delivery of fluids, drugs, and blood products, venous blood sampling, and central vein pressure monitoring in cardiac surgery. Catheter occlusion is a serious complication of SV catheterization during cardiac surgery, especially after sternal retractor expansion.

Methods

In this observational study, 303 patients who had successful right infraclavicular SV catheterization from September 2019 to April 2020 were enrolled to determine the incidence of catheter occlusion. After catheterization, the lumens of all catheters were checked for the ability to infuse and withdraw blood from the catheter before and after sternal retractor expansion. The patients’ characteristics, cannulation approach, on-pump or off-pump technique, occlusion of the catheter and its lumens, and any associated complications were recorded. The data were analyzed using IBM SPSS ver. 22.0 (IBM Corp., Armonk, NY, USA).

Results

Of the 303 patients studied, 205 were male (67.7%) and 98 were female (32.3%). Catheter occlusion occurred in 11 patients with on-pump cardiopulmonary bypass (CPB) (227 patients) and 4 patients with off-pump CPB (76 patients) (p=0.863). The incidence of catheter occlusion was 4.95% (15 of 303 patients) with no cases of simultaneous 3-lumen occlusion in a catheter. The most commonly occluded lumen was the distal lumen (57.92%). Simultaneous 2-lumen occlusion occurred in 4 patients. Catheter occlusion was found in 3 of 13 malpositioned catheters (23.07%).

Conclusion

The current study showed that malpositioning of the catheter tip was a risk factor for catheter occlusion and that the distal lumen of a triple-lumen catheter was the most commonly occluded lumen.

Comparison of the complications of open surgery versus laparoscopic technique in insertion of peritoneal dialysis catheter

Background:

Invention of peritoneal dialysis (PD) has opened new windows for patients under dialysis due to its fewer time requirement and being ambulatory in comparison to hemodialysis. Open surgery and laparoscopic technique have been utilized for peritoneal catheter embedding; however, data about the superior technique are controversial. This study aimed to assess the outcomes of open surgery versus laparoscopic technique and compare their complications in those with survival of over and less than a year in patients who need PD for the first time.

Materials and Methods:

This randomized clinical trial study was conducted on 121 cases admitted for PD. Patients were randomly divided into two groups undergoing either open or laparoscopic surgery for embedding PD catheter. Patients’ demographics, as well as PD function and complications, were followed for a 12-month duration and compared between the two groups.

Results:

Catheter survival for over 12 months occurred in 39 patients (65%) underwent laparoscopic surgery, and 45 (73.8%) patients underwent open surgery (P = 0.09). Complications, including catheter obstruction, leak, abdominal hernia, and peritonitis, were not statistically different between the two techniques over 12 months of survival (P > 0.05). Complications among the catheters with less than a year survival, including obstruction, leak, catheter displacement, hernia, and peritonitis, were not significantly different comparing open surgery with laparoscopic technique (P > 0.05).

Conclusion:

Considering complications, PD catheter implantation through laparoscopic surgery was not statistically different from open surgery, neither for those with less than 12 months of survival nor for those with over a year.

An antimicrobial impregnated urinary catheter that reduces mineral encrustation and prevents colonisation by multi-drug resistant organisms for up to 12 weeks

Two major complications of indwelling urinary catheterisation include infection and mineral encrustation of the catheter. Our antimicrobial urinary catheter (AUC) impregnated with rifampicin, triclosan, and sparfloxacin has demonstrated long-term protective activity against major uropathogens. This study aimed to firstly assess the ability of the AUC to resist mineral encrustation in the presence and absence of bacteria. Secondly, it aimed to investigate the AUC's anti-biofilm activity against multi-drug resistant organisms. There was no difference in surface roughness between AUC and control segments. In a static and a perfusion model, phosphate deposition was significantly reduced on AUCs challenged with P. mirabilis. Furthermore, none of the AUCs blocked during the 28 day test period, unlike controls. The AUC prevented colonisation by methicillin-resistant Staphylococcus aureus, methicillin-resistant Staphylococcus epidermidis, extended-spectrum beta-lactamase producing E. coli, and carbapenemase-producing E. coli for 12 consecutive weekly challenges. All three drugs impregnated into the catheter continued to exert protective activity throughout 12 weeks of constant perfusion. The drugs appear to migrate into the crystalline biofilm to continually protect against bacteria not it direct contact with the catheter surface. In conclusion, the AUC reduces mineral encrustation and may increase time to blockage in the presence of P. mirabilis, and does not predispose to mineral deposition under other conditions. It also offers 12 weeks of protection against multi-drug resistant bacteria. STATEMENT OF SIGNIFICANCE: Infection and associated mineral encrustation of urinary catheters are two serious complications of indwelling urinary catheters. Others have attempted to address this through various technologies such as coatings, dips, and surface modifications to prevent infection and/or encrustation. However, all current 'anti-infective' urinary catheter technologies are limited to short-term use. Some patients with spinal injuries, multiple sclerosis, stroke survivors and others use long-term catheters for 4-12 weeks at a time with multiple catheterisation possibly throughout the rest of their life. We present a urinary catheter for long-term use that is impregnated with three antimicrobials by a patient-protected process to prevent infection and encrustation for up to 12 weeks, the maximum lifetime of a long-term catheter before it is changed.

Next generation of ventricular catheters for hydrocephalus based on parametric designs

BACKGROUND

The flow pattern of the cerebrospinal fluid is probably the most important factor related to obstruction of ventricular catheters during the normal treatment of hydrocephalus. To better comprehend the flow pattern, we have carried out a parametric study via numerical models of ventricular catheters. In previous studies, the flow was studied under steady and, recently, in pulsatile boundary conditions by means of computational fluid dynamics (CFD) in three-dimensional catheter models.

OBJECTIVE

This study aimed to bring in prototype models of catheter CFD flow solutions as well to introduce the theory behind parametric development of ventricular catheters.

METHODS

A preceding study allowed deriving basic principles which lead to designs with improved flow patterns of ventricular catheters. The parameters chosen were the number of drainage segments, the distances between them, the number and diameter of the holes on each segment, as well as their relative angular position.

RESULTS

CFD results of previously unreleased models of ventricular catheter flow solutions are presented in this study. Parametric development guided new designs with better flow distribution while lowering the shear stress of the catheters holes. High-resolution 3D printed catheter solutions of three models and basic benchmark testing are introduced as well.

CONCLUSIONS

The next generation of catheter with homogeneous flow patterns based on parametric designs may represent a step forward for the treatment of hydrocephalus, by possibly broadening their lifespan.

Invention of the Guide Catheter Irrigation Monitoring Device for Neuroendovascular Therapy

Objective

The thromboembolic events during neuroendovascular therapy (NET) are the major complications of concern that can be occasionally fatal. The thrombotic occlusion of the guide catheter for NET is thought to be the risk of the thromboembolic events. We have developed an idea for inventing the monitoring system of the continuous irrigation through the guide catheter. We herein present a unique invention of the guide catheter irrigation monitoring device.

Methods

We have developed ideas for preventing the thrombotic occlusion of the guide catheter. In order to design a convenient device working in the practical use, we have consulted and shared the ideas with the electrical engineers about putting the invention.

Results

The guide catheter irrigation monitoring device (GCIMD) consisted of three parts of optical sensor, main body and electric adapter. In brief, the basic principles of working of the GCIMD are as follows. The optical sensor is attached to the dripping chamber of the line to irrigation solution. The main body had the small light and speaker to make an alarm sounds. The sensor monitors the dripping of flush solution. If the dripping stops more than three seconds, a warning alarm has been activated. So, the operating physicians can concentrate and check the guide catheter irrigation. After the use of the GCIMD, there was no major thromboembolic complication in conjunction with the thrombotic occlusion of the guide catheter in our institute.

Conclusion

We have developed a brilliant invention of the GCIMD for NET.

Peripherally InSerted CEntral catheter dressing and securement in patients with cancer: the PISCES trial. Protocol for a 2x2 factorial, superiority randomised controlled trial

INTRODUCTION

Around 30% of peripherally inserted central catheters (PICCs) fail from vascular, infectious or mechanical complications. Patients with cancer are at highest risk, and this increases morbidity, mortality and costs. Effective PICC dressing and securement may prevent PICC failure; however, no large randomised controlled trial (RCT) has compared alternative approaches. We designed this RCT to assess the clinical and cost-effectiveness of dressing and securements to prevent PICC failure.

METHODS AND ANALYSIS

Pragmatic, multicentre, 2×2 factorial, superiority RCT of (1) dressings (chlorhexidine gluconate disc (CHG) vs no disc) and (2) securements (integrated securement dressing (ISD) vs securement device (SED)). A qualitative evaluation using a knowledge translation framework is included. Recruitment of 1240 patients will occur over 3 years with allocation concealment until randomisation by a centralised service. For the dressing hypothesis, we hypothesise CHG discs will reduce catheter-associated bloodstream infection (CABSI) compared with no CHG disc. For the securement hypothesis, we hypothesise that ISD will reduce composite PICC failure (infection (CABSI/local infection), occlusion, dislodgement or thrombosis), compared with SED.

SECONDARY OUTCOMES

types of PICC failure; safety; costs; dressing/securement failure; dwell time; microbial colonisation; reversible PICC complications and consumer acceptability. Relative incidence rates of CABSI and PICC failure/100 devices and/1000 PICC days (with 95% CIs) will summarise treatment impact. Kaplan-Meier survival curves (and log rank Mantel-Haenszel test) will compare outcomes over time. Secondary end points will be compared between groups using parametric/non-parametric techniques; p values <0.05 will be considered to be statistically significant.

ETHICS AND DISSEMINATION

Ethical approval from Queensland Health (HREC/15/QRCH/241) and Griffith University (Ref. No. 2016/063). Results will be published.

TRIAL REGISTRATION

Trial registration number is: ACTRN12616000315415.

Cerebrospinal Fluid Shunting Complications in Children

Although cerebrospinal fluid (CSF) shunt placement is the most common procedure performed by pediatric neurosurgeons, shunts remain among the most failure-prone life-sustaining medical devices implanted in modern medical practice. This article provides an overview of the mechanisms of CSF shunt failure for the 3 most commonly employed definitive CSF shunts in the practice of pediatric neurosurgery: ventriculoperitoneal, ventriculopleural, and ventriculoatrial. The text has been partitioned into the broad modes of shunt failure: obstruction, infection, mechanical shunt failure, overdrainage, and distal catheter site-specific failures. Clinical management strategies for the various modes of shunt failure are discussed as are research efforts directed towards reducing shunt complication rates. As it is unlikely that CSF shunting will become an obsolete procedure in the foreseeable future, it is incumbent on the pediatric neurosurgery community to maintain focused efforts to improve our understanding of and management strategies for shunt failure and shunt-related morbidity.

Efficacy of Long-Acting Octreotide on Reducing Mucus Production in Patients With Ileal Neobladder

PURPOSE

To evaluate the efficacy of long-acting-release octreotide (trade name Sandostatin) on decreasing mucus secretion, thus reducing catheter obstruction after radical cystectomy and orthotopic reconstruction.

PATIENTS AND METHODS

In this double-blind, placebo-controlled study, we treated 73 cases of radical cystectomy between the years 2008 and 2014; 65 were deemed eligible for the study. Cases were randomly divided into 2 groups. Group A (n = 32) received 2 doses of 20 mg intramuscular long-acting-release octreotide 4 weeks before and on the day of surgery, while group B (n = 33) received placebo. Catheter irrigation was only performed when there was an obstruction due to a mucus plug. The need for catheter irrigation and the volume of mucus produced by the neobladder were evaluated and compared between the 2 groups.

RESULTS

The average number of neobladder irrigations required to treat mucus plugs was 2.3 ± 1.5 in group A and 9.5 ± 4.3 in group B (P < .001) before hospital discharge. This number changed to 2.5 ± 1.5 versus 11.4 ± 2.7 in groups A and B, respectively (P < .001), after discharge from the hospital. The 24-hour mucus production at the end of the first week was 5.4 ± 2.7 mL versus 21.5 ± 5.6 mL in groups A and B, respectively (P < .001). At the end of the third week, this amount changed to 5.5 ± 2.3 mL versus 21.8 ± 5.6 mL in groups A and B, respectively (P < .001).

CONCLUSION

Two injections of long-acting-release octreotide can dramatically reduce mucus production and hence catheter obstruction due to mucus plugs after radical cystectomy and orthotopic reconstruction.

Small versus Large Catheters for Ventriculostomy in the Management of Intraventricular Hemorrhage

OBJECTIVE

Intraventricular hemorrhage (IVH) often requires the insertion of an external ventricular drain (EVD), but blood clots could occlude the catheters. Large EVD catheters may help to reduce the risk of catheter occlusion. Here, we compared small catheters with large catheters for ventriculostomy in patients suffering from IVH.

METHODS

We conducted a retrospective cohort study. Patients were included if they had IVH requiring EVD insertion. We then compared baseline characteristics and outcomes of patients treated with large catheters with patients treated with small catheters.

RESULTS

Between 2011 and 2015, 227 IVH patients were admitted to our 2 hospitals. Among the patients, 28 were treated in first intention with large catheters, and 46 controls were identified. Insertion of large catheter decreased the risk of temporary and permanent catheter occlusion without impact on the occurrence of intracerebral hemorrhage (ICH) related to catheter insertion. There was 38.5% more catheter-related infections in the small catheter group when compared with the large catheter group, but this result was not significant. There was no impact on functional outcomes. Surprisingly, the rate of death was higher in the large catheter group.

CONCLUSIONS

In patients suffering from IVH, the use of large catheters for EVD reduced the risk of catheter occlusion without increasing the risk of ICH related to catheter insertion. The risk of catheter-related infection may subsequently be decreased by using large catheters. A prospective randomized trial would be necessary to seek out any benefits that large catheters may provide for the risk of death and functional outcome.

Varied flushing frequency and volume to prevent peripheral intravenous catheter failure: a pilot, factorial randomised controlled trial in adult medical-surgical hospital patients

Background

Research has identified high failure rates of peripheral intravenous catheter (PIVC) and varied flushing practices.

Methods

This is a single-centre, pilot, non-masked, factorial randomised controlled trial. Participants were adults, with a PIVC of expected use ≥24 hours (n = 160), admitted to general medical or surgical wards of a tertiary referral hospital in Queensland (Australia). Patients were randomly allocated to one of four flush groups using manually prepared syringes and 0.9 % sodium chloride: 10 mL or 3 mL flush, every 24 or 6 hours. The primary endpoint was PIVC failure, a composite measure of occlusion, infiltration, accidental dislodgement and phlebitis.

Results

PIVC average dwell was 3.1 days. PIVC failure rates per 1000 hours were not significantly different for the volume intervention (4.84 [3 mL] versus 7.44 [10 mL], p = 0.06, log-rank). PIVC failure rates per 1000 hours were also not significantly different for the frequency intervention (5.06 [24 hour] versus 7.34 [6 hour], p = 0.05, log-rank). Cox proportional hazard regression found neither the flushing nor frequency intervention, or their interaction (p = 0.21) to be significantly associated with PIVC failure. However, female gender (hazard ratio [HR] 2.2 [1.3–3.6], p < 0.01), insertion in hand/posterior wrist (HR 1.7 [1.0–2.7], p < 0.05) and the rate per day of PIVC access (combined flushes and medication pushes) (HR 1.2 [1.1–1.4], p < 0.01) significantly predicted PIVC failure.

Conclusion

Neither increased flushing volume nor frequency significantly altered the risk of PIVC failure. Female gender, hand/posterior wrist placement and episodes of access (flushes and medication) may be more important. Larger, definitive trials are feasible and required.

Trial registration

Australian and New Zealand Clinical Trials Registry: ACTRN12615000025538. Registered on 19 January 2015.

[Heparin for clearance of peripherally inserted central venous catheter in newborns: an in vitro study]

Objective:

To compare the efficacy of two concentrations of heparin to clear the lumen of in vitro clotted neonatal peripherally inserted central catheters (PICCs).

Methods:

This is an in vitro, experimental quantitative study of 76 neonatal 2.0-Fr PICCs coagulated in vitro. The catheters were divided into two groups of 38 PICCs each. In both groups an infusion of low molecular weight heparin was administered with a dose of 25IU/mL for Group 1 and 50IU/mL for Group 2. The negative pressure technique was applied to the catheters of both groups at 5, 15 and 30min and at 4h to test their permeability. Kaplan-Meier survival analysis was used to verify the outcome of the groups according to time intervals.

Results:

The comparison between both groups in the first 5min showed that more catheters from Group 2 were cleared compared to Group 1 (57.9 vs. 21.1%, respectively). Kaplan-Meier survival analysis showed that less time was needed to clear catheters treated with 50IU/mL of heparin (p<0.001).

Conclusions:

The use of low molecular weight heparin at a concentration of 50IU/mL was more effective in restoring the permeability of neonatal PICCs occluded in vitro by a clot, and the use of this concentration is within the safety margin indicated by scientific literature.

[Procedure adverse events: nursing care in central venous catheter fracture]

In a intensive care unit (ICU) there are many factors that can lead to the occurrence of adverse events. A high percentage of these events are associated with the administration of drugs. Diagnostic tests, such as computed tomography, is common in critically ill patients and technique can be performed with injection of contrast agent to enhance the visualization of soft tissue. The contrast is a medication and the nurse is responsible for its proper administration. The management of the critically ill patient is complex. ICU team and radiology shares responsibility for the care and safety of the patient safety during the transfer and performing tests with contrast. The World Health Organisation patient safety strategies, recommends analysing errors and learning from them. Therefore, it was decided to investigate the causes of the category E severity adverse events that occurred in a patient who was admitted to the ICU for septic shock of abdominal origin. An abdominal computed tomography was performed with contrast which was injected through a central venous catheter. The contrast did not appear in the image. What happened? Causal analysis helped to understand what triggered the event. A care plan and an algorithm were drafted to prevent it from happening again, with the following objectives: improving knowledge, skills and promoting positive attitudes towards patient safety, working at primary, secondary and tertiary care levels.