Interventions to manage occluded central venous access devices: An umbrella review

The main objective of this umbrella review is to synthesise available evidence from systematic reviews on the effectiveness of interventions for the management of occlusions in central venous access devices. CVADS have been extensively utilised among the critically ill since the 1950s however have also been linked to an increase in catheter complications. CVAD occlusion can occur in 14%-36% of patients within 1-2 years of catheter placement and is a longstanding complication. Umbrella methodology was applied to review five healthcare databases. Databases were searched for publications from 2009 and 2022 and electronic keywords searches were conducted. The authors searched for reviews that reported on any intervention to prevent, maintain or manage patency of the central venous access devices within an acute care setting. Of the 278 articles identified from the initial search a total of 11 articles were identified. This umbrella review concluded that education enhances patient outcomes and decreases occlusion rates. Further studies are required to explore occlusion reduction strategies in relation to flushing and locking.

A 27-Year Experience With Day Surgery Transurethral Resection of the Prostate

Introduction Transurethral resection of the prostate (TURP) is the standard surgical procedure for obstructive symptoms of the lower urinary tract when medical management fails. Progression in TURP procedures has led to reduced catheterization time following transurethral prostatic resection. This study describes the methods and results of TURP performed in the day surgery setting. Materials and methods This retrospective study was performed at a day surgical hospital serving a patient population of more than 200,000 people. Over a 27-year period, a total of 1,123 patients with a mean age of 73.6 years (range: 49 to 91 years) underwent same-day conventional (electrosurgical monopolar) transurethral prostatic resection. Of the procedure, 43 patients (11%) received spinal anaesthesia, and the remainder received general anaesthesia.  Results Over the years, there has been an increase in the use of medication to manage bladder outflow obstructive symptoms, which has led to the preoperative post-micturition volumes of urine being increased (>200 ml) at the time of surgical intervention. The mean American Urological Association (AUA) score was 22 (range: 10-35). Due to the reduced bladder tone preoperatively and the noted intraoperative distension of the bladder, early catheter removal is contraindicated in these patients. The mean duration of catheterization was 6.4 days (range: two to 28 days). No patient was readmitted to the hospital for retention of urine. However, 11 patients in the series had re-catheterization due to failure of micturition after the removal of the catheter. No patients were admitted to the hospital for clot retention or sepsis postoperatively. This resulted in the patients being discharged home with a catheter in place, which became our standard practice. Conclusion Conventional transurethral resection of the prostate can be effectively managed in the day surgery setting with minimal morbidity. This improves the patient's quality of life as well as the burden on hospital costs. Additionally, the outpatient nature of day surgery may lead to decreased overall healthcare expenses for both the patient and the healthcare system. As healthcare systems continue to prioritize streamlined and patient-centred approaches, day surgery for TURP emerges as a viable and advantageous option.

Effectiveness of the T-Control catheter: A study protocol

Background

Foley catheters have been subject to limited development in the last few decades. They fulfil their basic function of draining urine from the bladder but cause other associated problems. T-Control is a new silicone Foley catheter with an integrated fluid control valve whose design aims to reduce the risks associated with bladder catheterisation by a multifactorial approach. The general purpose of this study is to evaluate the effectiveness and cost-effectiveness of the T-Control catheter versus the Foley-type catheter in patients with Acute Urine Retention (AUR).

Study design

This is a pragmatic, open, multicentre, controlled clinical trial with random allocation to the T-Control catheter or a conventional Foley-type catheter in patients with AUR.

Endpoints

The magnitude of infections will be analysed as a primary endpoint. While as secondary endpoint, the following will be analysed: rate of symptomatic and asymptomatic infections; days free of infection; quality of life-related to self-perceived health; indication of associated antibiotic treatments; determination of biofilm; number of catheter-related adverse events; use of each type of catheterisation's healthcare resources; level of satisfaction and workload of health professionals and acceptability of the T-Control device as well as the patient experience.

Patients and methods

Eligible patients are male adults aged ≥50 years, with AUR and with an indication of bladder catheterisation for at least 2 weeks. The estimated sample size is 50 patients. Patient follow-up includes both the time of catheter insertion and its removal or change 2 weeks later, plus 2 weeks after this time when the patient will be called for an in-depth interview.

The economic burden of difficult intravenous access in the emergency department from a United States' provider perspective

Background

Peripheral intravenous catheter placement is one of the most common invasive procedures that nurses will perform, especially in emergency departments.

Aims

This early analysis aimed to quantify the economic burden associated with intravenous therapy in patients presenting in emergency departments with difficult intravenous access, receiving traditional peripheral intravenous catheters. This may inform the opportunity for improvement for investment in nursing tools and services regarding difficult venous access burden reduction.

Methods

Model parameter data were obtained from published literature where possible via a targeted literature review for the terms including relative variations of 'Difficult Venous Access', 'burden', and 'costs', or elicited from expert clinical opinion. A simple decision tree model was developed in Microsoft® Excel 2016. Results included number of insertion attempts, number of patients requiring escalation, catheter failures due to complications, healthcare professional (e.g. nurse) time, and total costs (including/excluding health care professional time). Sensitivity analyses were performed.

Results

The model considers 64,000 individuals presenting in the emergency department annually, of which 75% (48,000) require a peripheral intravenous catheter; of these 22% (10,560) are estimated to have difficult venous access. The total cost burden of difficult venous access is estimated to be $890,095 per year/$84.29 per patient with difficult venous access, including the cost of clinician time. Key total cost drivers include the population size treated in the emergency department annually, the proportion of midlines placed by a specialist IV (intravenous access) nurse and the percentage of patients with difficult venous access.

Conclusion

This is the first formal analysis estimating the significant economic burden of difficult venous access in emergency departments via peripheral intravenous catheter placement, a task frequently performed by nurses. Further studies are needed to evaluate nursing-centric strategies for reducing this burden. Additionally, adoption of a concise definition is needed, as is routine use of reliable assessment tools so that future cost analyses can be better contextualised.

Implementation frameworks, strategies and outcomes used in peripheral intravenous catheter studies: A systematic review

AIMS

The aim of this study was to critically evaluate implementation frameworks, strategies and/or outcomes used to optimise peripheral intravenous catheter (PIVC) care and/or promote guideline adherence.

BACKGROUND

Although a considerable volume of research has investigated the effectiveness of PIVC interventions and treatments to promote performance and prevent harm, how to best implement this evidence into dynamic clinical settings and populations is not well understood. Implementation science is central to translating evidence-based knowledge to the bedside; however, there is a gap in identifying the best implementation framework, strategies and/or outcomes to optimise PIVC care and/or guideline adherence.

DESIGN

A systematic review.

METHOD

The review was conducted using innovative automation tools. Five databases and clinical trial registries were searched on 14 October 2021. Qualitative and quantitative PIVC intervention studies reporting implementation strategies were included in the review. Data were extracted independently by experienced researchers in pairs. The Mixed Method Appraisal tool was used to assess the quality of individual studies. Narrative synthesis was used to present the findings. The systematic review was reported following the PRISMA checklist.

RESULTS

Of 2189 references identified, 27 studies were included in the review. Implementation frameworks were used in 30% (n = 8) of studies, with most used during the preparation (n = 7, 26%) and delivery phase (n = 7, 26%) and then evaluation phase (n = 4, 15%). Multifaceted strategies were commonly adopted (n = 24, 89%) to promote PIVC care or study interventions which were clinician (n = 25, 93%) and patient-targeted (n = 15, 56%). The most commonly reported implementation outcomes were fidelity (n = 13, 48%) and adoption (n = 6, 22%). Most studies were scored as low quality (n = 18, 67%).

CONCLUSION

We call for researchers and clinicians to work together and use implementation science frameworks to guide study design, implementation and evaluation in future PIVC studies, to improve evidence translation and thereby improve patient outcomes.

Electric toy car to reduce anxiety before a cardiac catherisation: randomised controlled trial

BACKGROUND

Anxiety before an invasive intervention is associated in children with persistent psychological disorders. We studied the effect of the transfer to the catheterisation room by an electric toy car on the anxiety of children and their parents before a cardiac catheterisation.

METHODS

Forty-eight children with a median age of 5.6 years [4.2-7.0] were randomised to either riding on an electric car to go to the catheterisation laboratory or being transported lying supine on a gurney. Anxiety assessments were performed by a physician blinded to group allocation on the day before the procedure (T0) and at anaesthesia induction (T1). The modified Yale Preoperative Anxiety Scale Short Form (mYPAS-SF) and visual analogue scale for anxiety (VAS-A) were used in the children and the VAS-A in the parents.

RESULTS

The mYPAS-SF, VAS-A-child, and the VAS-A-parent scores were significantly higher at T1 than at T0 (p < 0.001, p < 0.001, and p = 0.005, respectively). The primary outcome (the median mYPAS-SF score at T1) was not significantly different in the two groups when males and females were combined. At T1, the VAS-A-child score, however, was significantly lower in the intervention than the control group (22 versus 55, p < 0.001). In the boys, the median mYPAS-SF score at T1 was significantly lower in the intervention group (25.0 versus 51.0, p = 0.024). No difference was observed in girls. The VAS-A parent score was lower at T1 in the intervention group (60 versus 87, p = 0.05).

CONCLUSION

Riding to the catheterisation laboratory on an electric toy car decreased anxiety in boys and decreased parental anxiety.

Remotely supervised ultrasound-guided peripheral intravenous cannulation training: A prospective cohort study examining success rates and patient experience

Introduction

Ultrasound-guided peripheral intravenous cannulation (USGPIVC) benefits patients with difficult intravenous access (DIVA) through visualising otherwise non-visible and non-palpable veins. Supervised live-case training is an important component of learning this skill, but supervisor availability can present a barrier limiting or delaying staff completing their training.

Aims

The aim of this study was to determine the first-attempt success rate of newly trained USGPIVC inserters using remote supervision and timely written feedback based on app-based screen recordings taken during insertion. Secondary aims were overall procedural success, and inserter and patient experiences.

Methods

This study is an observational cohort study carried out between October and December 2021. Fourteen newly trained junior medical officers (JMOs) were eligible to utilise USGPIVC on a minimum of five consenting patients while simultaneously recording the ultrasound screen during insertion to capture their technique. Feedback was generated following expert review of these recordings against a standardised feedback tool.

Results

Average first-attempt success was 71% (n = 72) in the 102 patients recruited. The average time for JMOs to receive feedback was 30 h, and 13 JMOs (93%) felt well supported and completed the remote training pathway. The majority of patients were female (n = 59; 58%), were aged 41-80 years (n = 75; 74%) and had ≥2 risk factors for DIVA (n = 57; 56%).

Conclusions

First-attempt success rates were similar when comparing remote supervision used in this study to direct supervision used by other studies.This finding supports incorporating remote supervision into training guidelines for USGPIVC as an alternative method of supervision, particularly when supervisor availability is limited.

Comparison of out-of-plane short axis with in-plane long axis for ultrasound-guided radial arterial cannulation: A systematic review with trial sequential analysis of randomised controlled trials

Background

It is controversial whether the short-axis out-of-plane or long-axis in-plane approach is a better needling technique for ultrasound-guidance radial artery cannulation. We aimed to compare the efficacy and safety of the two approaches for ultrasound-guided radial artery cannulation.

Methods

A systematic search of Medline, Embase, the Cochrane Library, and Web of Science for relevant articles published until 1 May 2021 was conducted. Randomised controlled trials comparing the long-axis in-plane with short-axis out-of-plane approaches were included. Review Manager software version 5.4, STATA version 14.2, and trial sequential analysis (TSA) version 0.9.5.10 Beta were used for statistical analysis. Risk of bias and methodological quality of all studies included in this review were assessed according to the Cochrane Collaboration tool for the risk of bias. Subgroup analyses and meta-regression were performed to explore sources of heterogeneity.

Results

The rate of cannula insertion success on the first attempt was similar between the short-axis out-of-plane and long-axis in-plane approaches (RR = 1.03; 95% CI: 0.83 to 1.28; P = 0.79; I ² = 83.0%). No significant differences were observed in total time to successful cannulation between the two approaches (MD = -3.9; 95% CI:-18.30 to 10.49; P = 0.6; I ² = 97%). However, the required information size for the success rate of the first attempt and total time to successful cannulation was not reached.

Conclusion

It remains inconclusive whether short-axis out-of-plane is a better choice for radial arterial cannulation than the long-axis in-plane approach. Inexperienced operators may need more attempts and longer ultrasound location time with the short-axis out-of-plane technique.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42021236098].

Nurses' Involvement in the Development and Usability Assessment of an Innovative Peripheral Intravenous Catheterisation Pack: A Mix-Method Study

Guaranteeing peripheral venous access is one of the cornerstones of modern healthcare. Recent evidence shows that the lack of adequate clinical devices can result in the provision of substandard care to patients who require peripheral intravenous catheterization (PIVC). To address this challenge, we aimed to develop a PIVC pack for adult patients and assess the usability of this new device.

METHODS

Following a mix-method design, the PIVC pack development and usability assessment were performed in two phases with the involvement of its potential end-users (nurses). In phase one (concept and semi-functional prototype assessment), focus group rounds were conducted, and a usability assessment questionnaire was applied at each stage. In phase two (pre-clinical usability assessment), a two-arm crossover randomised controlled trial (PIVC pack versus traditional material) was conducted with nurses in a simulated setting. Final interviews were conducted to further explore the PIVC pack applicability in a real-life clinical setting.

RESULTS

High average usability scores were identified in each study phase. During the pre-clinical usability assessment, the PIVC pack significantly reduced procedural time (Z = -2.482, p = 0.013) and avoided omissions while preparing the required material (Z = -1.977, p = 0.048). The participating nurses emphasised the pack's potential to standardise practices among professionals, improve adherence to infection control recommendations, and enhance stock management.

CONCLUSIONS

The developed pack appears to be a promising device that can assist healthcare professionals in providing efficient and safe care to patients requiring a PIVC. Future studies in real clinical settings are warranted to test its cost-effectiveness.

Comparison of ultrasound-guided peripheral intravenous catheter insertion with landmark technique in paediatric patients: A systematic review and meta-analysis

BACKGROUND

Paediatric peripheral intravenous catheter (PIVC) insertion using traditional landmark insertion technique can be difficult.

AIM

To systematically review the evidence comparing landmark to ultrasound guidance for PIVC insertion in general paediatric patients.

STUDY DESIGN

Cochrane methodology to systematically search for randomised controlled trials comparing landmark to ultrasound-guided PIVC insertion.

DATA SOURCES

Cochrane Central Register of Controlled Trials, US National Library of Medicine, Cumulative Index to Nursing and Allied Health, Embase.

DATA EXTRACTION

English-language, paediatric trials published after 2000, reporting first-attempt insertion success, overall PIVC insertion success, and/or time to insert were included. Central venous, non-venous and trials including only difficult intravenous access were excluded. Data were independently extracted and critiqued for quality using GRADE by three authors, and analysed using random effects, with results expressed as risk ratios (RR), mean differences (MD) and 95% confidence intervals (CI). Registration (CRD42020175314).

RESULTS

Of 70 titles identified, 5 studies (995 patients; 949 PIVCs) were included. There was no evidence of an effect of ultrasound guidance, compared to landmark, for first-attempt insertion success (RR 1.27; 95% CI 0.90-1.78; I²  = 88%; moderate quality evidence), overall insertion success (RR 1.14; 95% CI 0.90-1.44; I²  = 82%; low quality evidence), or time to insertion (mean difference -3.03 min; 95% CI -12.73 to 6.67; I²  = 92%; low quality evidence).

LIMITATIONS

Small sample sizes, inconsistent outcomes and definitions in primary studies precluded definitive conclusions.

CONCLUSIONS

Large clinical trials are needed to explore the effectiveness of ultrasound guidance for PIVC insertion in paediatrics. Specifically, children with difficult intravenous access might benefit most from this technology.

Acute lower extremity ischaemia after surgical interventricular communication closure in a newborn

We report a 5-month-old infant who developed an unexpected acute ischaemia of the right lower limb following a surgical perimembranous interventricular communication closure. This rare case of ischaemia was due to an occlusive right common iliac artery dissection. It was early managed by angioplasty with two ABSORB® bioresorbable stents, resulted in complete revascularisation of the right leg.

Impact of 3D-printed models in meetings with parents of children undergoing interventional cardiac catheterisation

BACKGROUND

Paediatric interventional catheterisation has consistently improved in recent decades, with often highly successful outcomes. However, progress is still required in terms of the information delivered to parents and how parental anxiety is managed.

AIM

To investigate the impact of cardiac printed models on improving parental understanding and alleviating anxiety before interventional catheterisation.

METHODS

The parents of children undergoing interventional cardiac catheterisation were prospectively enrolled in the study. A questionnaire highlighting knowledge and understanding of the condition and cardiac catheterisation per se was scored on a scale of 1-30. The State-Trait Anxiety Inventory (STAI), which generates current anxiety scores, was also used before and after the pre-catheterisation meeting. The "printing group" received an explanation of catheterisation using the device and a three-dimensional (3D) model, while the "control group" received an explanation using only the device and a manual drawing.

RESULTS

In total, 76 parents of 50 children were randomly assigned to a "control group" (n = 38) or "printing group" (n = 38). The groups were comparable at baseline. The level of understanding and knowledge improved after the "control group" and "printing group" meetings (+5.5±0.8 and +10.2±0.8; p < 0.0001 and p < 0.0001, respectively). A greater improvement was documented in the "printing group" compared to the "control group" (p < 0.0001). The STAI score also improved after the explanation was given to both groups (-1.8±0.6 and -5.6±1.0; p < 0.0001 and p < 0.0001). The greatest improvement was noted in the "printing group" (p = 0.0025). Most of the parents (35/38 from the "printing group") found the models to be extremely useful.

CONCLUSION

3D-printed models improve parental knowledge and understanding of paediatric cardiac catheterisation, thereby reducing anxiety levels.

Coolsense® versus EMLA® for peripheral venous cannulation in adult volunteers: A randomised crossover trial

Peripheral venous cannulation (PVC) is a commonly performed invasive medical procedure. Topical treatments such as the eutectic mixture of local anaesthetics (EMLA®, Aspen Pharmacare Australia Pty Ltd, St Leonards, NSW) attenuate the associated pain, but are limited by requiring up to one hour of application before becoming effective. The Coolsense® (Coolsense Medical Ltd., Tel Aviv, Israel) pain numbing applicator is a new device using a cryoanalgesic means to anaesthetise skin within seconds. Coolsense is being increasingly used for cannulation, but comparative studies are lacking. We recruited 64 healthy adult volunteers to this open-label two sequence, two period randomised crossover trial. Participants had two 20 gauge venous cannulae inserted, one on the dorsum of each hand. Each cannulation attempt was preceded by treatment with Coolsense or an EMLA patch containing 2.5% lidocaine and 2.5% prilocaine. The primary outcome was participant pain using the 0-10 numerical pain rating scale. Secondary outcomes were participant satisfaction scores on a 0-10 scale, treatment preference, and failed cannulation attempts. Participants were randomly assigned to either the Coolsense EMLA (n = 32) or EMLA Coolsense (n = 32) sequence. All participants completed the trial. The pooled mean paired difference of the numerical pain rating scale was -1.84 (95% confidence intervals -1.28 to -2.41; P < 0.001) in favour of EMLA. The pooled mean paired difference for satisfaction score was 2.26 (95% confidence intervals 1.46 to 3.07; P < 0.001) higher with EMLA. Most participants preferred EMLA over Coolsense (P < 0.001). There was no significant difference regarding failed cannulation between the two treatments (P = 0.14). Among healthy individuals undergoing elective PVC, EMLA was associated with reduced pain, increased satisfaction, and was the preferred treatment compared to Coolsense.

Fissurectomy Versus Lateral Internal Sphincterotomy in the Treatment of Chronic Anal Fissure: A Randomized Control Trial

Introduction

An anal fissure is defined as a longitudinal split in the distal anoderm which extends from the anal verge to the dentate line. Fissures can be of primary or secondary type. The posterior midline is the most common location for primary fissures, while, anterior primary fissures, though rare, are more common in females. The cause of primary fissure is idiopathic. But secondary fissures are associated with other systemic diseases and can occur at an abnormal position anywhere in the anoderm. A high percentage of acute fissures heal spontaneously within three weeks with conservative medical management comprising of a high fiber diet, warm sitz bath, and topical analgesic with steroids. Secondary anal fissures will not heal in any form of treatment until the primary cause is addressed. These fissures often need surgical treatment. The lateral internal sphincterotomy (LIS) is one of the most practiced treatments for chronic anal fissure. Nonetheless, anal incontinence is one of the worrisome complications of LIS. Fissurectomy is one of the options among those techniques which address the issues with LIS. Some studies showed that patients with chronic fissures who are refractory to medical treatment responded well to fissurectomy. Hence, this study was conducted to compare the outcomes of fissurectomy and lateral internal sphincterotomy in the treatment of chronic anal fissure and compare recurrence and postoperative complications among both the procedures.

Methods

All consecutive patients attending the department of surgery with chronic fissure and age above 18 years were included in the study. All the included patients were randomized into two groups (fissurectomy and LIS) using the serially numbered opaque-sealed envelope (SNOSE) technique. The patients were discharged on the third day. The first visit was scheduled after two weeks and subsequent visits on the first and second months. Then the patients were followed up by telephonic conversation for the next six months. At the end of the follow-up, post-surgical complications were enquired, recorded, and interpreted.

Results

In the present study, out of a total of 87 patients, 80 patients were included in the study. Among all the patients, 16 patients (20%) developed retention of urine. Four patients in the LIS group showed retention of urine whereas in the fissurectomy group it was twelve. The difference was not statistically significant (p-value: 0.025). A total of 10 patients required catheterization postoperatively. More patients in the fissurectomy group developed incontinence to flatus (p-value: 0.02). Incontinence to liquid and solid was significantly higher in the fissurectomy group (p-value: 0.03 and 0.002, respectively).

Conclusion

In the present study, it was found that LIS was a better treatment option for chronic anal fissure than Fissurectomy. The postoperative complications were less in LIS than in fissurectomy. But the recurrence was higher in the LIS group while there was no recurrence in the fissurectomy group.

Cardiovascular events in perimembranous ventricular septal defect with left ventricular volume overload: a French prospective cohort study (FRANCISCO)

The long-term prospective multi-centre nationwide (French) observational study FRANCISCO will provide new information on perimembranous ventricular septal defect with left ventricular overload but no pulmonary hypertension in children older than 1 year. Outcomes will be compared according to treatment strategy (watchful waiting, surgical closure, or percutaneous closure) and anatomic features of the defect. The results are expected to provide additional guidance about the optimal treatment of this specific population, which is unclear at present.

BACKGROUND

The management of paediatric isolated perimembranous ventricular septal defect (pmVSD) with left ventricle (LV) volume overload but no pulmonary arterial hypertension (PAH) remains controversial. Three therapeutic approaches are considered: watchful waiting, surgical closure, and percutaneous closure. We aim to investigate the long-term outcomes of these patients according to anatomic pmVSD characteristics and treatment strategy.

METHODS

The Filiale de Cardiologie Pediatrique et Congénitale (FCPC) designed the FRANCISCO registry, a long-term prospective nationwide multi-centre observational cohort study sponsored by the French Society of Cardiology, which enrolled, over 2 years (2018–2020), patients older than 1 year who had isolated pmVSD with LV volume overload. Prevalent complications related to pmVSD at baseline were exclusion criteria. Clinical, echocardiographic, and functional data will be collected at inclusion then after 1, 5, and 10 years. A core lab will analyse all baseline echocardiographic data to depict anatomical pmVSD features. The primary outcome is the 5-year incidence of cardiovascular events (infective endocarditis, sub-aortic stenosis, aortic regurgitation, right ventricular outflow tract stenosis, tricuspid regurgitation, PAH, arrhythmia, stroke, haemolysis, heart failure, or death from a cardiovascular event). We plan to enrol 200 patients, given the 10% estimated 5-year incidence of cardiovascular events with a 95% confidence interval of ±5%. Associations linking anatomical pmVSD features and treatment strategy to the incidence of complications will be assessed.

CONCLUSIONS

The FRANSCICO study will provide the long-term incidence of complications in patients older than 1 year with pmVSD and LV volume overload. The results are expected to improve guidance for treatment decisions.

Coronary artery spasm in a 15-year-old male in diabetic ketoacidosis

Coronary artery disease and myocardial infarction are known complications of long-standing diabetes mellitus in adults, but coronary artery spasm is far more rare and has not been reported in children. We present a 15-year-old male in diabetic ketoacidosis who developed diffuse ST segment elevations and elevated troponin with normal coronary arteries on coronary angiography and no signs of pericarditis that was due to coronary artery spasm.

How to change a suprapubic catheter effectively

This 'How to' article explains how to change a suprapubic catheter in a safe, effective and supportive manner. Nurses undertaking this procedure must ensure they have the knowledge and skills to do so and work within the limits of their competence. The patient - and/or their carer where appropriate - should be involved in shared decision-making about the care of their suprapubic catheter and any catheter changes. This will increase the patient's confidence and acceptance of the suprapubic catheter and its function. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of.

Effectiveness of simulation-based peripheral intravenous catheterization training for nursing students and hospital nurses: A systematic review and meta-analysis

BACKGROUND

Peripheral intravenous catheterisation (PIVC) is a complex procedure.

AIM

This study reviewed studies evaluating the effects of different simulators in comparison with traditional methods used in PIVC training for nursing students and hospital nurses.

DESIGN

A systematic review and meta-analysis of randomised (RCT) and non-randomised controlled (N-RCT) studies.

METHODS

MEDLINE, Cochrane, Scopus, ERIC, Web of Science, and ScienceDirect were searched using PIVC, simulation and nursing education. The quality of evidence was assessed using the GRADE system; the risk of bias was assessed using the RoB 2 (for RCTs) and A Cochrane Risk of Bias Assessment Tool for N-RCTs. The study was conducted as per the PRISMA guidelines.

RESULTS

In total, 2,812 records were identified, and 12 studies published between 2002 and 2018 were finally included. Most studies included Virtual IV simulator and the plastic IV arm model in PIVC training for hospital nurses and nursing students, reported on outcomes such as PIVC-related knowledge, skills, confidence, state/trait anxiety and satisfaction. Seven studies were included in the meta-analysis, the effect sizes for all the outcomes ranged from small to moderate. However, the effect sizes were non-significant for all outcomes. The quality of evidence was assessed as being low for skills, knowledge, satisfaction, and trait/state anxiety, and moderate for confidence.

CONCLUSIONS

The effect of Virtual IV training on PIVC-related skills, knowledge, satisfaction and anxiety among nursing students and hospital nurses, in comparison with the plastic arm training method, remains unclear. However, Virtual IV training was found to increase PIVC confidence.

RELEVANCE TO CLINICAL PRACTICE

There is a small effect in favour of VR in PIVC education although non-significant. More evidence is needed to determine the superiority of simulation methods. In PIVC training of nurses and nursing students, hospitals and schools can choose a method in accordance with their resources.

TRIAL REGISTRATION

PROSPERO 2019 CRD42019124599.

Care of patients undergoing removal of an indwelling urinary catheter

An indwelling urinary (Foley) catheter may be used in the management of various urological conditions, such as intractable incontinence and urinary retention, or as part of treatment regimens such as chemotherapy. Although some catheters may be required for long-term use, healthcare practitioners should regularly assess whether the device is still necessary and if it can be removed. This is because urinary catheters are a highly invasive intervention and their use is associated with a range of potential complications, including healthcare-associated infection and trauma to the neck of the bladder. This article outlines the procedure for the safe removal of a urinary catheter, including the patient care and monitoring required before, during and after this procedure. It also explains the complications that are associated with catheter removal and how these can be prevented and managed.

Managing complications associated with the use of indwelling urinary catheters

The insertion of an indwelling urethral urinary catheter is an invasive procedure that is commonly undertaken in healthcare settings. However, there are several risks and potential complications associated with these devices, so their use should be avoided where possible. It is important that nurses are equipped with the necessary knowledge and skills not only to assess if a patient requires a catheter, but also to minimise the risk of associated complications and to understand how these can be managed. This article discusses some of the common complications that can occur with the use of indwelling urinary catheters, including: catheter-associated urinary tract infections; catheter blockages; encrustation; negative pressure; bladder spasm and trauma; and, in men, paraphimosis. It also explains the steps that nurses can take to reduce the risk of these complications and how to manage them effectively.

Anticipating Urinary Retention Following Total Hip and Total Knee Replacements

Introduction

Urinary retention is a widely recognised postoperative complication. Although anecdotally lower limb arthroplasty is linked with high rates of urinary retention, there are no current accepted standards for determining which patients are at higher risk and should therefore be offered intra operative catheterisation.

Materials and Methods

One hundred patients, 55 females and 45 males, who underwent uncomplicated total hip or total knee replacements at Furness General Hospital were recruited between January and April 2017.

Results

Post-operative urinary retention was seen frequently, with 38 patients (38%) requiring post-operative catheterisation. Twenty-one males (46%) developed postoperative retention compared to 17 (30%) of females, representing a statistically significant increase in risk seen in male patients. (p 0.009). Post-operative urinary retention requiring catheterisation was associated with increasing age, with those over 75 years having a significantly higher risk than those less than 75 years irrespective of gender (p 0.04). There was no significant difference in urinary retention rates between patients who had general (n=21) or spinal anaesthetic (n=79) with 33% of GA patients and 39% of spinal anaesthetic patients requiring catheterisation (p 0.17).

Conclusion

There are increased rates of urinary retention seen in lower limb arthroplasty patients than those described in the general surgical population, with male patients and all those over 75 years of age having a significantly higher risk. Clinically, it may therefore be sensible to consider offering routine intra operative catheterisation to this cohort of patients.

Left heart hypoplasia operated using double pulmonary arterial banding with double arterial duct stenting: A case report

Hypoplastic left heart syndrome is a heterogeneous group of congenital cardiac malformations which associates hypoplastic/aplastic left ventricle, mitral and aortic valve, hypoplastic/atresia and severe aortic artery coarctation, and represents a medical-surgical emergency. We present a case of a newborn hospitalised in three clinics (two clinics from Timisoara and one from Vienna), and operated for hypoplastic left heart syndrome, without aortic coarctation, using a mixed technique cardiovascular repair surgery. The initial therapeutic conduct included maintaining the permeability of the arterial canal with prostaglandin E1. At the Vienna General Hospital, at the age of 17 days, bilateral banding of the pulmonary artery was performed and, at the age of 20 days, during the cardiac catheterisation, the Rashkind procedure (balloon atrial septostomy) was performed, with two stents being implanted in the arterial canal. Postoperative complications were postcardiotomy syndrome, pneumonia with Enterococcus faecalis and Stenotrophomonas maltophilia, sepsis with methicillin-resistant Staphylococcus aureus, coagulopathy, mixed anaemia, and metabolic acidosis. The patient died 1 month after the intervention due to cardiorespiratory arrest, bilateral congestive heart failure, left heart hypoplasia with shunt through the arterial canal and pulmonary artery banding, multiorgan failure, and severe secondary haemorrhagic disease. In conclusion, the initial cardiac surgical reconstruction consisted of a mixed technique, and anticoagulant medical treatment with heparin, antibiotics (bacterial endocarditis prophylaxis to be performed throughout life); postintervention hypoxic and infectious complications resulted in multiorgan failure and death.

Compliance with aspirin in paediatric CHD post-percutaneous transcatheter occlusion: a cross-sectional study

BACKGROUND

Predictors of compliance with aspirin in children following cardiac catheterisation have not been identified. The aim of this study is to identify the caregivers' knowledge, compliance with aspirin medication, and predictors of compliance with aspirin in children with Congenital Heart Disease (CHD) post-percutaneous transcatheter occlusion.

METHODS

A cross-sectional explorative design was adopted using a self-administered questionnaire and conducted between May 2017 and May 2018. Recruited were 220 caregivers of children with CHD post-percutaneous transcatheter occlusion. Questionnaires included child and caregivers' characteristics, a self-designed and tested knowledge about aspirin scale (scoring scale 0-2), and the 8-item Morisky Medication Adherence Scale (scoring scale 0-8). Data were analysed using multivariate binary logistic regression analysis to identify predictors of compliance with aspirin.

RESULTS

Of the 220 eligible children and caregivers, 210 (95.5%) responded and 209 surveys were included in the analysis. The mean score of knowledge was 7.25 (standard deviation 2.27). The mean score of compliance was 5.65 (standard deviation 1.36). Child's age, length of aspirin use, health insurance policies, relationship to child, monthly income, and knowledge about aspirin of caregivers were independent predictors of compliance with aspirin (p < 0.05).

CONCLUSION

Caregivers of children with CHD had an adequate level of knowledge about aspirin. Compliance to aspirin medication reported by caregivers was low. Predictors of medium to high compliance with aspirin were related to the child's age and socio-economic reasons. Further studies are needed to identify effective strategies to improve knowledge, compliance with medication, and long-term outcomes of children with CHD.

Impact of arm choice for peripherally inserted central catheter (PICC) insertion on patients: a cross-sectional study

Background: Arm choice for peripherally inserted central catheter (PICC) insertion is often determined by PICC nurses. Objectives: To explore the impact of arm choice (dominant or non-dominant) on the rate of catheter-related complications and degree of comfort in patients with PICCs. Design: A cross-sectional study. Methods: We used questionnaires and scales to collect 255 patients' general information, catheter-related complications and comfort degree. They were divided into two groups (PICC inserted in the dominant or non-dominant arm). Results: There were significant differences in the rate of PICC occlusion and insertion site bleeding (χ ² = 9.829, P < 0.05; χ ² = 6.502, P < 0.05), both were lower in the non-dominant group than in the dominant group. Patients in the non-dominant group had a higher degree of comfort (Z = -10.166, P < 0.01). Conclusion: Inserting into non-dominant arms is related to the lower rate of catheter-related complications and higher degree of comfort for patients. Impact statement: These findings provide practical evidence for nurses to make a better choice.

Prevalence and predictors of peripherally inserted central venous catheter associated bloodstream infections in cancer patients: A multicentre cohort study

Despite increasing use, the exact prevalence and predictors of peripherally inserted central catheter-associated bloodstream infection (PICC-CLABSI) in hospitalized patients with cancer are not elucidated.This retrospective cohort study included consecutive patients who underwent peripherally inserted central catheter (PICC) placement in 4 institutions (during 12 months in 3 hospitals and 10 months in 1 hospital). The prevalence of PICC-CLABSI was evaluated. The association between predictors and PICC-CLABSI were analyzed using Cox proportional hazards regression models and Kaplan-Meier survival analysis with log-rank tests.During the study period, 539 PICCs were inserted in 484 patients for a total of 10,841 catheter days. PICC-CLABSI occurred in 25 (5.2%) patients, with an infection rate of 2.31 per 1000 catheter days. PICC for chemotherapy (hazards ratio [HR] 11.421; 95% confidence interval (CI), 2.434-53.594; P = .019), double lumen catheter [HR 5.466; 95% CI, 1.257-23.773; P = .007], and PICC for antibiotic therapy [HR 2.854; 95% CI, 1.082-7.530; P = .019] were associated with PICC-CLABSI.PICC for chemotherapy or antibiotics, and number of catheter lumens are associated with increased risk of PICC-CLABSI in cancer patients. Careful assessment of these factors might help prevent PICC-CLABSI and improve cancer patients care.

Flushing of peripheral intravenous catheters: A pilot, factorial, randomised controlled trial of high versus low frequency and volume in paediatrics

AIM

To test the feasibility of an efficacy trial comparing different flushing frequencies and volumes to reduce peripheral intravenous cannula (PIVC) failure in paediatric inpatients.

METHODS

Pilot, 2 × 2 factorial, randomised controlled trial comparing PIVC flushing techniques in intervention pairs: (i) low volume (3 mL) versus high volume (10 mL); and (ii) low frequency (24 hourly) versus high frequency (6 hourly). Patients were excluded if: fluids were restricted, weight < 5 kg, PIVC already in situ for >24 h or continuous infusion. The primary end-point was feasibility (eligibility, recruitment, retention, protocol adherence, missing data and sample size estimates) of a large trial. Secondary end-points were PIVC failure (composite and individual), bloodstream infection and mortality.

RESULTS

A total of 919 children were screened from April to November 2015, with 55 enrolled. Screening feasibility criteria were not met, mainly due to continuous infusions and PIVCs in situ >24 h or planned for imminent removal. However, 80% of eligible participants consented, 2% withdrew, protocol adherence was 100%, and there was no missing primary end-point data. PIVC failure was significantly higher (hazard ratio = 2.90, 95% confidence interval: 1.11-7.54) in the 3 mL compared to the 10 mL group. There was no difference in failure between frequency groups (hazard ratio = 0.91, 95% confidence interval: 0.36-2.33). There was no interaction effect (P = 0.22).

CONCLUSION

Trial feasibility proved challenging due to eligibility criteria, which could be improved with additional recruiting staff. Firm conclusions cannot be made based on this small sample, but flush volume may impact PIVC failure.

Implementation of a paediatric peripheral intravenous catheter care bundle: A quality improvement initiative

AIM

To improve paediatric peripheral intravenous catheter (PIVC) care through the implementation of care bundles.

METHODS

A pre-post study using mixed methods (clinical audit, staff survey, parent interviews) in 2016 at a tertiary paediatric hospital in Brisbane was conducted to evaluate the effectiveness of a PIVC insertion and maintenance bundle to improve PIVC insertion, promote function and support practice. Participants included children with PIVC, parents and staff inserting and managing PIVCs. A mnemonic care bundle, SUCCESS PIVCS (At insertion: Skills, Understand and prepare, Consent, Clean site, Escalate, Secure, Sign and document. During management: Prompt removal, Inspect hourly, Vein patency, Clean hands and Scrub the hub), was developed and implemented via visual aids, workshops and change champions. During audit, PIVC first-attempt insertion success, PIVC failure, PIVC dwell, escalation to senior clinicians and insertion and management procedures were measured.

RESULTS

Pre-implementation audit (n = 102) and survey (n = 117) data described high rates of PIVC failure (n = 50; 49%), difficulty obtaining equipment (n = 64; 55%) and pressure to insert (n = 50; 43%). Parent interviews (n = 15) identified lack of communication, fear, appreciation of skilled technicians and technology and care giver roles as key to improving the experience. After implementation first-attempt insertion success (45 vs. 62%; risk ratio 1.37, 95% confidence interval 1.05-1.78), first-attempt escalation to senior clinicians (junior doctor 72 vs. 41%; P = <0.001) and median PIVC dwell (40 vs. 52 h; P = 0.021) improved.

CONCLUSION

This multi-level care bundle demonstrated improvements in the insertion and management of PIVCs; however, PIVC failure remained high.

Prevention and management of urinary catheter blockages in community settings

Self-management of long-term urinary catheters can be challenging for patients, and recurrent catheter blockages may cause concern among patients, carers and healthcare professionals. Catheter blockages are a significant challenge for nurses practising in community settings, because frequent and unplanned catheter changes can be costly to healthcare services in terms of time and resources. This article details evidence-based recommendations for the assessment and diagnosis of catheter blockages, as well as the identification of risk factors. It also explains the interventions that can be used to prevent and manage catheter blockages and describes the role of the nurse in supporting patients with a long-term catheter in situ in community settings.

Nurses' decision-making about intravenous administration set replacement: A qualitative study

AIMS AND OBJECTIVES

To explore nurses' decision-making regarding intravenous administration set replacement for vascular access device infusions in paediatric and adult clinical settings.

BACKGROUND

Intravenous administration sets are routinely replaced at regular intervals in clinical practice with the goal of preventing catheter-related bloodstream infection; however, emerging evidence is challenging traditional hang-time durations. Nurses' perceptions and contextual factors affecting decision-making for administration set replacement have not been assessed previously.

DESIGN

Qualitative study using focus groups with contextualism methodology and inductive analysis.

METHOD

During November-December 2016, eight semi-structured focus groups were conducted with 38 nurses at two metropolitan hospitals in Queensland, Australia. Interviews were audio-recorded and transcribed. Two authors independently reviewed transcripts and extracted significant statements using Braun and Clarke's 7-step method of thematic analysis. The COREQ checklist provided a framework to report the study methods, context, findings, analysis and interpretation.

RESULTS

Five key themes emerged from the analysis: (a) infection prevention, (b) physical safety, (c) patient preference, (d) clinical knowledge and beliefs, and (e) workload. Administration set replacement can be a complex task, particularly when patients have multiple infusions and incompatible medications. Nurses drew on perceptions of patient preference, as well as previous experience, knowledge of peer experts and local policies, to aid their decisions.

CONCLUSIONS

Nurses use clinical reasoning to balance patient safety and preferences with competing workplace demands when undertaking administration set replacement. Nurses rely on previous experience, hospital and medication manufacturer policies, and peer experts to guide their practice.

RELEVANCE TO CLINICAL PRACTICE

Nurses at times deviate from clinical guidelines in the interests of patient acuity, nurses' experience and workload. The findings of this study indicate nurses also balance considerations of patient preference and safety with these competing demands.

Veinplicity versus heat treatment for vein dilation: A randomised cross-over study

BACKGROUND

Peripheral intravenous cannulation is one of the most common invasive procedures for hospitalised patients. Patients with difficult venous access require special measures to facilitate cannulation. Veinplicity applies mild electrical stimulation to forearm veins to aid vessel dilation. To assess this new technique, we compared its effect on the veins to that of standard heat treatment.

METHODS

In all, 20 volunteers were randomised to receive either application of heat packs to the forearm and later stimulation with Veinplicity or the same two treatments in reverse order. Ultrasound measurements of the basilic, cephalic and brachial veins were taken at intervals during and after treatment and compared with baseline values.

RESULTS

The mean maximum vein diameter increase from baseline was significantly higher with Veinplicity than with heat packs (49.94% ± 23.55% vs 36.26% ± 23.09%, p = 0.021). In addition, the mean duration of the dilatory effect was significantly longer with Veinplicity than with heat packs (9.7 ± 3.9°min vs 4.9 ± 2.2°min, p < 0.001).

CONCLUSION

Veinplicity dilates forearm veins more effectively and for a longer time than commonly used heat packs. This new treatment option appears to be a valuable addition to the vascular access toolkit, with the potential to improve first-attempt cannulation rates and spare patients from discomfort, pain and iatrogenic vessel trauma.

A new approach of three-dimensional guidance in paediatric cath lab: segmented and tessellated heart models for cardiovascular interventions in CHD

BACKGROUND

Optimal imaging is essential for catheter-based interventions in CHD. The three-dimensional models in volume-rendering technique currently in use are not standardised. This paper investigates the feasibility and impact of novel three-dimensional guidance with segmented and tessellated three-dimensional heart models in catheterisation of CHD. In addition, a nearly radiation-free two- to three-dimensional registration and a biplane overlay were used.Methods and resultsWe analysed 60 consecutive cases in which segmented tessellated three-dimensional heart models were merged with live fluoroscopy images and aligned using the tracheal bifurcation as a fiducial mark. The models were generated from previous MRI or CT by dedicated medical software. We chose the stereo-lithography format, as this promises advantage over volume-rendering-technique models regarding visualisation. Prospects, potential benefits, and accuracy of the two- to three-dimensional registration were rated separately by two paediatric interventionalists on a five-point Likert scale. Fluoroscopy time, radiation dose, and contrast dye consumption were evaluated. Over a 10-month study period, two- to three-dimensional image fusion was applied to 60 out of 354 cases. Of the 60 catheterisations, 73.3% were performed in the context of interventions. The accuracy of two- to three-dimensional registration was sufficient in all cases. Three-dimensional guidance was rated superior to conventional biplane imaging in all 60 cases. We registered significantly smaller amounts of used contrast dye (p<0.01), lower levels of radiation dose (p<0.02), and less fluoroscopy time (p<0.01) during interventions concerning the aortic arch compared with a control group.

CONCLUSIONS

Two- to three-dimensional image fusion can be applied successfully in most catheter-based interventions of CHD. Meshes in stereo-lithography format are accurate and base for standardised and reproducible three-dimensional models.

The management of paediatric neurogenic bladder: an approach in a resource-poor setting

BACKGROUND

If untreated, paediatric neurogenic bladder can cause renal failure and urinary incontinence. It is usually caused by neural tube defects such as myelomeningocele. Children with a neurogenic bladder should be monitored from birth and management should aim to preserve renal function and achieve social continence. This article outlines the management options appropriate for these children in resource-poor settings.

ASSESSMENT

In most low- and middle-income countries, a general lack of awareness of the neurological effects on the urinary tract results in late presentation, usually with urological complications even when spina bifida is diagnosed early. Physical examination must include neurological examination for spinal deformities and intact sacral reflexes. About 90% of children with occult spinal dysraphisms will have cutaneous sacral lesions. The work-up includes urinalysis, serial ultrasound of the urinary tracts and urodynamics. Urodynamic assessment is essential for the diagnosis and prognosis of the paediatric neurogenic bladder. In poorly resourced settings, simple eyeball urodynamics can be performed in the absence of a conventional urodynamic set-up.

TREATMENT

Clean intermittent catheterisation (CIC), the mainstay of treatment, is most suitable for resource-poor settings because it is effective and inexpensive. Antimuscarinic drugs such as oxybutynin complement CIC by reducing detrusor overactivity. Intravesical injection of Botox and bladder augmentation surgery is required by a small subset of patients who fail to respond to combined CIC and oxybutynin therapy.

CONCLUSION

Children with neurogenic bladder in resource-poor settings should have early bladder management to preserve renal function and provide social continence.

Making a choice of catheterisation gel and the role of chlorhexidine

It is estimated that over 90 000 people in the UK community live with an indwelling catheter ( Wilson, 2016 ). It is essential that a lubricating gel is used during catheterisation, as this helps to reduce the risk of pain, trauma and infection ( Loveday et al, 2014 ; National Institute for Health and Care Excellence, 2012 ). Chlorhexidine is an antiseptic contained in many catheterisation gels. Evidence demonstrates that increasing numbers of patients are experiencing hypersensitivity reactions to this ingredient ( Australian and New Zealand College of Anaesthetists, 2014 ). This article considers the range of catheterisation gel choices available to clinicians and the importance of selecting the correct gel for each patient. It addresses the benefits of using OptiLube Active CHG Free (with lidocaine 2%) - the only catheterisation gel currently available in the UK that contains the benefits of local anaesthetic without chlorhexidine - and recommends that this should be the gel of choice for non-specialist staff conducting catheterisations without individual patient assessments.

Echocardiographic right ventricular function correlations with cardiac catheterisation data in biventricular congenital heart patients

BACKGROUND

Newer echocardiographic techniques may allow for more accurate assessment of right ventricular function. Adult studies have correlated these echocardiographic measurements with invasive data, but minimal data exist in the paediatric congenital heart population. The purpose of this study was to evaluate echocardiographic measurements that correlate best with right ventricular systolic and diastolic catheterisation parameters.

METHODS

Patients with two-ventricle physiology who underwent simultaneous echocardiogram and cardiac catheterisation were included in this study. Right ventricular systolic echocardiographic data included fractional area change, displacement, tissue Doppler imaging s' wave, global longitudinal strain, and strain rate s' wave. Diastolic echocardiographic data included tricuspid E and A waves, tissue Doppler imaging e' and a' waves, and strain rate e' and a' waves. E/tissue Doppler imaging e', tissue Doppler imaging e'/tissue Doppler imaging a', E/strain rate e', and strain rate e'/strain rate a' ratios were also calculated. Catheterisation dP/dt was used as a marker for systolic function and right ventricular end-diastolic pressure for diastolic function.

RESULTS

A total of 32 patients were included in this study. The median age at catheterisation was 3.1 years (0.3-17.6 years). The DP/dt was 493±327 mmHg/second, and the right ventricular end-diastolic pressure was 7.7±2.4 mmHg. There were no significant correlations between catheterisation dP/dt and systolic echocardiographic parameters. Right ventricular end-diastolic pressure correlated significantly with strain rate e' (r=-0.4, p=0.02), strain rate a' (r=-0.5, p=0.03), and E/tissue Doppler imaging e' (r=0.4, p=0.04).

CONCLUSION

Catheterisation dP/dt did not correlate with echocardiographic measurements of right ventricular systolic function. Strain rate and tissue Doppler imaging analysis significantly correlated with right ventricular end-diastolic pressure. These values should be further studied to determine whether they may be used as an alternative method to estimate right ventricular end-diastolic pressure in this patient population.

The challenges of upskilling health care assistants in community nursing

Community care is at the forefront of the National Health Service reforms. Role redistribution from registered nurses to health care assistants is growing. This paper examines the challenges of upskilling community health care assistants to undertake catheterisation for uncomplicated patients in the community. Social constructivist methods facilitated reflective practice. Challenges included fears around delegation, accountability and the responsibilities involved in supporting the development of health care assistants. Recommendations suggest that community health care assistants offer a valuable and much needed contribution to health care delivery and are enthusiastic to upskill in catheterisation. However, reluctance from community registered nurses around delegation delayed the process. Registered nurses will need to address these fears and engage in workforce planning to proactively influence role developments and safe practice. National guidance needs to be structured around clear pathways to support these valued participants in delivering health care.

Cranberry capsules to prevent nosocomial urinary tract bacteriuria after pelvic surgery: a randomised controlled trial

OBJECTIVE

To evaluate whether cranberries are able to prevent postoperative urinary bacteriuria in patients undergoing pelvic surgery and receiving transurethral catheterisation.

DESIGN

Randomised, double-blind, placebo-controlled trial.

SETTINGS

French tertiary Care centre, University Hospital.

POPULATION

A total of 272 women undergoing pelvic surgery aged 18 or older.

METHODS

Participants undergoing pelvic surgery were randomised to 36 mg cranberry (proanthocyanidins, PAC) or placebo once daily for 10 days. Statistical analysis was performed by a chi-square test.

MAIN OUTCOME MEASURES

The primary and secondary outcomes were postoperative bacteriuria, defined by a positive urine culture, within the first 15 and 40 days, respectively.

RESULTS

Two hundred and fifty-five participants received the intended treatment: 132 (51.8%) received PAC and 123 (48.2%) received placebo. There were no significant differences in baseline demographics, intra-operative characteristics or duration and type of catheterisation between the two groups. PAC prophylaxis did not reduce the risk of bacteriuria treatment within 15 days of surgery [27% bacteriuria with PAC compared with 25% bacteriuria with placebo: relative risk 1.05, 95% CI 0.78-1.4, P = 0.763). The same result was observed on day 40. Bacteriuria occurred more often in older women with increased length of catheterisation.

CONCLUSION

Immediate postoperative prophylaxis with PAC does not reduce the risk of postoperative bacteriuria in patients receiving short-term transurethral catheterisation after pelvic surgery.

TWEETABLE ABSTRACT

PAC prophylaxis does not reduce the risk of postoperative bacteriuria in patients undergoing pelvic surgery.

How to remove an indwelling urinary catheter in female patients

Rationale and key points This article aims to assist nurses to undertake the removal of an indwelling urinary catheter in female patients in a safe, timely, effective and patient-centred manner, while maintaining the patient's privacy and dignity. It is important for the nurse to be competent in undertaking this procedure, and to be aware of local and national policies on catheter removal. » Indwelling urinary catheters should be changed only when clinically necessary, or according to the manufacturer's guidelines. » Urinary catheters should be removed using sterile equipment. » The balloon of the indwelling catheter must be deflated before removal, and the catheter should be removed slowly to minimise trauma. Reflective activity 'How to' articles can help you update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of: » How you think this article might change your practice when removing an indwelling urinary catheter. » How you could use this article to educate your colleagues.

The effects of the Trendelenburg position and the Valsalva manoeuvre on internal jugular vein diameter and placement in children

INTRODUCTION

We compared the effects of various surgical positions, with and without the Valsalva manoeuvre, on the diameter of the right internal jugular vein (RIJV).

METHODS

We recruited 100 American Society of Anesthesiologists physical status class I patients aged 2-12 years. The patients' heart rate, blood pressure, peripheral oxygen saturation and end-tidal CO2 pressure were monitored. Induction of anaesthesia was done using 1% propofol 10 mg/mL and fentanyl 2 µg/kg, while maintenance was achieved with 2% sevoflurane in a mixture of 50/50 oxygen and air (administered via a laryngeal mask airway). The RIJV diameter was measured using ultrasonography when the patient was in the supine position. Thereafter, it was measured when the patient was in the supine position + Valsalva, followed by the Trendelenburg, Trendelenburg + Valsalva, reverse Trendelenburg, and reverse Trendelenburg + Valsalva positions. A 15° depression or elevation was applied for the Trendelenburg position, and an airway pressure of 20 cmH2O was applied in the Valsalva manoeuvre. During ultrasonography, the patient's head was tilted 20° to the left.

RESULTS

When compared to the mean RIJV diameter in the supine position, the mean RIJV diameter was significantly greater in all positions (p < 0.001) except for the reverse Trendelenburg position. The greatest increase in diameter was observed in the Trendelenburg position with the Valsalva manoeuvre (p < 0.001).

CONCLUSION

In paediatric patients, the application of the Trendelenburg position with the Valsalva manoeuvre gave the greatest increase in RIJV diameter. The reverse Trendelenburg position had no significant effect on RIJV diameter.

Stenting of the right ventricular outflow tract in a symptomatic newborn with tetralogy of Fallot

This case describes a successful percutaneous stent implantation to critical stenosis of the right ventricle outflow tract in a female neonate with tetralogy of Fallot. At the time of the procedure she had poor development of the pulmonary arteries (McGoon and Nakata index 1.45 and 120, respectively). Stent implantation ensured an immediate increase in oxygen saturation level, and the physiological pulsating blood inflow caused good development of the pulmonary arteries during 12 months of follow up (McGoon 2.5; Nacata Index 436). After this time she was qualified for surgery and underwent surgical correction without using a patch or conduit implantation.

Prophylactic antibiotics in interventional paediatric cardiac catheterisation: old habits die hard?

Antibiotic prophylaxis in congenital cardiac disease has long been a topic of debate. Although there is little dispute around antibiotic cover for surgical procedures and catheter interventions where foreign material is being inserted, there are little data specific to non-device-placement procedures such as atrial septostomy or balloon valvotomy. We sought to assess the effect of routine prophylaxis on post-interventional infections via a retrospective pseudo-randomised analysis, and an online survey on paediatric interventional cardiologists in the United Kingdom and United States.

Fibromyxoid excrescence of the aortic valve that manifested after catheterisation and required resection

A 2-year-old boy developed fibromyxoid excrescence of the aortic valve 2 years after balloon dilatation for simple coarctation. Transthoracic echocardiography showed a mobile mass on the non-coronary cusp of the aortic valve. Definitive diagnosis was achieved after operative resection. This pathology was attributed to injury during catheter manipulation. Catheterised patients should be followed up carefully to avoid missing morphological changes.

Reducing urinary tract infections in catheterised patients

Urinary tract infections in catheterised patients continue to present a challenge in reducing healthcare-associated infection. In this article, an infection prevention and control team in one NHS trust reports on using audit results to focus attention on measures to reduce bacterial infections. Educational initiatives have an important role in reducing infection, but there is no single solution to the problem. Practice can be improved using a multi-targeted approach, peer review and clinical audit to allow for shared learning and experiences. These, along with informal education in the clinical area and more formal classroom lectures, can ultimately lead to improved patient outcomes.

Understanding and Minimising Occupational Radiation in the Catheterisation Laboratory with PISAX and the ACIST CVi® Contrast Delivery System

This paper provides an overview of radiation exposure and its associated risks in the cardiac catheterisation laboratory (cath lab), as well as strategies to minimise radiation exposure for operators, cath lab staff and patients. The benefits of using a mobile 2 mm lead equivalent radiation shield (PISAX) and adoption of an automated contrast injection system (the ACIST CVi® Contrast Delivery System) are discussed, and the potential advantages of their combination are reviewed.

A structured course teaching junior doctors invasive medical procedures results in sustained improvements in self-reported confidence

Pressure on working hours has led to a decrease in opportunities for training in invasive medical procedures for junior doctors. The effect of a structured course on immediate and medium-term changes in self-reported confidence was investigated. A one-day model-based practical course was run on two separate occasions teaching central venous line placement, lumbar puncture, Seldinger-technique chest drain insertion and knee joint aspiration. Attendees were asked to indicate their confidence in each procedure on a 10-point Likert scale before, immediately after and three months after the course. Significant improvements in self-reported confidence were seen for all procedures which were sustained at three months. Feedback was universally positive. Practical preclinical training may be a useful adjunct to patient-based training in invasive procedures. The course was particularly popular with foundation year trainees: ideally this training should be available before trainees' first exposure in the clinical setting.

Percutaneous technique for the reduction of knotted coronary catheters

During coronary angiography knotting of a coronary catheter is a recognised complication. It commonly results through excessive manipulation of a catheter in an attempt to engage the right coronary artery. Although simple manoeuvres of the catheter can often result in resolution of a kink, tighter knots may not be amenable to such measures. There is, however, little published material regarding its best management. We present five cases of cardiac catheterisation complicated by catheter knotting and present a novel percutaneous technique for their reduction.