Strategies for the removal of short-term indwelling urethral catheters in adults

BACKGROUND

Urinary catheterisation is a common procedure, with approximately 15% to 25% of all people admitted to hospital receiving short-term (14 days or less) indwelling urethral catheterisation at some point during their care. However, the use of urinary catheters is associated with an increased risk of developing urinary tract infection. Catheter-associated urinary tract infection (CAUTI) is one of the most common hospital-acquired infections. It is estimated that around 20% of hospital-acquired bacteraemias arise from the urinary tract and are associated with mortality of around 10%. This is an update of a Cochrane Review first published in 2005 and last published in 2007.

OBJECTIVES

To assess the effects of strategies for removing short-term (14 days or less) indwelling catheters in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 17 March 2020), and reference lists of relevant articles.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs that evaluated the effectiveness of practices undertaken for the removal of short-term indwelling urethral catheters in adults for any reason in any setting.

DATA COLLECTION AND ANALYSIS

Two review authors performed abstract and full-text screening of all relevant articles. At least two review authors independently performed risk of bias assessment, data abstraction and GRADE assessment.

MAIN RESULTS

We included 99 trials involving 12,241 participants. We judged the majority of trials to be at low or unclear risk of selection and detection bias, with a high risk of performance bias. We also deemed most trials to be at low risk of attrition and reporting bias. None of the trials reported on quality of life. The majority of participants across the trials had undergone some form of surgical procedure. Thirteen trials involving 1506 participants compared the removal of short-term indwelling urethral catheters at one time of day (early morning removal group between 6 am to 7 am) versus another (late night removal group between 10 pm to midnight). Catheter removal late at night may slightly reduce the risk of requiring recatheterisation compared with early morning (RR 0.71, 95% CI 0.53 to 0.96; 10 RCTs, 1920 participants; low-certainty evidence). We are uncertain if there is any difference between early morning and late night removal in the risk of developing symptomatic CAUTI (RR 1.00, 95% CI 0.61 to 1.63; 1 RCT, 41 participants; very low-certainty evidence). We are uncertain whether the time of day makes a difference to the risk of dysuria (RR 2.20; 95% CI 0.70 to 6.86; 1 RCT, 170 participants; low-certainty evidence). Sixty-eight trials involving 9247 participants compared shorter versus longer durations of catheterisation. Shorter durations may increase the risk of requiring recatheterisation compared with longer durations (RR 1.81, 95% CI 1.35 to 2.41; 44 trials, 5870 participants; low-certainty evidence), but probably reduce the risk of symptomatic CAUTI (RR 0.52, 95% CI 0.45 to 0.61; 41 RCTs, 5759 participants; moderate-certainty evidence) and may reduce the risk of dysuria (RR 0.42, 95% CI 0.20 to 0.88; 7 RCTs; 1398 participants; low-certainty evidence). Seven trials involving 714 participants compared policies of clamping catheters versus free drainage. There may be little to no difference between clamping and free drainage in terms of the risk of requiring recatheterisation (RR 0.82, 95% CI 0.55 to 1.21; 5 RCTs; 569 participants; low-certainty evidence). We are uncertain if there is any difference in the risk of symptomatic CAUTI (RR 0.99, 95% CI 0.60 to 1.63; 2 RCTs, 267 participants; very low-certainty evidence) or dysuria (RR 0.84, 95% CI 0.46 to 1.54; 1 trial, 79 participants; very low-certainty evidence). Three trials involving 402 participants compared the use of prophylactic alpha blockers versus no intervention or placebo. We are uncertain if prophylactic alpha blockers before catheter removal has any effect on the risk of requiring recatheterisation (RR 1.18, 95% CI 0.58 to 2.42; 2 RCTs, 184 participants; very low-certainty evidence) or risk of symptomatic CAUTI (RR 0.20, 95% CI 0.01 to 4.06; 1 trial, 94 participants; very low-certainty evidence). None of the included trials investigating prophylactic alpha blockers reported the number of participants with dysuria.

AUTHORS' CONCLUSIONS

There is some evidence to suggest the removal of indwelling urethral catheters late at night rather than early in the morning may reduce the number of people who require recatheterisation. It appears that catheter removal after shorter compared to longer durations probably reduces the risk of symptomatic CAUTI and may reduce the risk of dysuria. However, it may lead to more people requiring recatheterisation. The other evidence relating to the risk of symptomatic CAUTI and dysuria is too uncertain to allow us to draw any conclusions. Due to the low certainty of the majority of the evidence presented here, the results of further research are likely to change our findings and to have a further impact on clinical practice. This systematic review has highlighted the need for a standardised set of core outcomes, which should be measured and reported by all future trials comparing strategies for the removal of short-term urinary catheters. Future trials should also study the effects of short-term indwelling urethral catheter removal on non-surgical patients.

Catheter management after benign transurethral prostate surgery: RAND/UCLA Appropriateness Criteria

OBJECTIVES

To formally assess the appropriateness of different timings of urethral catheter removal after transurethral prostate resection or ablation. Although urethral catheter placement is routine after this common treatment for benign prostatic hyperplasia (BPH), no guidelines inform duration of catheter use.

STUDY DESIGN

RAND/UCLA Appropriateness Methodology.

METHODS

Using a standardized, multiround rating process (ie, the RAND/UCLA Appropriateness Methodology), an 11-member multidisciplinary panel reviewed a literature summary and rated clinical scenarios for urethral catheter duration after transurethral prostate surgery for BPH as appropriate (ie, benefits outweigh risks), inappropriate, or of uncertain appropriateness. We examined appropriateness across 4 clinical scenarios (no preexisting catheter, preexisting catheter [including intermittent], difficult catheter placement, significant perforation) and 5 durations (postoperative day [POD] 0, 1, 2, 3-6, or ≥7).

RESULTS

Urethral catheter removal and first trial of void on POD 1 was rated appropriate for all scenarios except clinically significant perforations. In this case, waiting until POD 3 was deemed the earliest appropriate timing. Waiting 3 or more days to remove the catheter for patients with or without preexisting catheter needs, or for those with difficult catheter placement in the operating room, was rated as inappropriate.

CONCLUSIONS

We defined clinically relevant guidance statements for the appropriateness of urethral catheter duration after transurethral prostate surgery. Given the lack of guidelines and this robust expert panel approach, these ratings may help clinicians and healthcare systems improve the consistency and quality of care for patients undergoing transurethral surgery for BPH.

Removal of failed dental implants revisited: Questions and answers

Objectives

This narrative review is aiming on showing reasons for implant failure, removal techniques, and respective clinical considerations; further, the survival rate of implants in previous failed sites is examined.

Materials and methods

Questions have been formulated, answered, and discussed through a literature search including studies assessing implant failure and removal up to 2018.

Results

Studies describing reasons for implant failure, implant removal techniques, and the reinsertion of implants in a previous failed site (n = 12) were included. To date, peri-implantitis is the main reason for late implant failure (81.9%). Trephine burs seem to be the best-known method for implant removal. Nevertheless, the counter-torque-ratchet-technique, because of the low invasiveness, should be the first choice for the clinician. Regarding zirconia implant removal, only scarce data are available. Implantation in previously failed sites irrespective of an early or late failure results in 71% to 100% survival over 5 years.

Conclusion

If removal is required, interventions should be based on considerations regarding minimally invasive access and management as well as predictable healing. (Post)Operative considerations should primarily depend on the defect type and the consecutive implantation plans.

When guidelines conflict: patient safety, quality of life, and CAUTI reduction in patients with spinal cord injury

The current Medicare payment structure and some of the recent guidelines aimed at reducing catheter-associated urinary tract infections may be generating a financial incentive for the protocolized, systematic removal of indwelling catheters in hospitalized patients-including those with spinal cord injury. This creates a tension with the Consortium for Spinal Cord Medicine's clinical practice guidelines for the management of neurogenic bladder. This article presents a series of cases and a discussion of the implications with regard to patient safety and quality of life.

Clinically-indicated replacement versus routine replacement of peripheral venous catheters

BACKGROUND

US Centers for Disease Control guidelines recommend replacement of peripheral intravenous catheters (PIVC) no more frequently than every 72 to 96 hours. Routine replacement is thought to reduce the risk of phlebitis and bloodstream infection. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation or infection. Costs associated with routine replacement may be considerable. This is the third update of a review first published in 2010.

OBJECTIVES

To assess the effects of removing peripheral intravenous catheters when clinically indicated compared with removing and re-siting the catheter routinely.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 18 April 2018. We also undertook reference checking, and contacted researchers and manufacturers to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials that compared routine removal of PIVC with removal only when clinically indicated, in hospitalised or community-dwelling patients receiving continuous or intermittent infusions.

DATA COLLECTION AND ANALYSIS

Three review authors independently reviewed trials for inclusion, extracted data, and assessed risk of bias using Cochrane methods. We used GRADE to assess the overall evidence certainty.

MAIN RESULTS

This update contains two new trials, taking the total to nine included studies with 7412 participants. Eight trials were conducted in acute hospitals and one in a community setting. We rated the overall certainty of evidence as moderate for most outcomes, due to serious risk of bias for unblinded outcome assessment or imprecision, or both. Because outcome assessment was unblinded in all of the trials, none met our criteria for high methodological quality.Primary outcomesSeven trials (7323 participants), assessed catheter-related bloodstream infection (CRBSI). There is no clear difference in the incidence of CRBSI between the clinically indicated (1/3590) and routine change (2/3733) groups (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.08 to 4.68), low-certainty evidence (downgraded twice for serious imprecision).All trials reported incidence of thrombophlebitis and we combined the results from seven of these in the analysis (7323 participants). We excluded two studies in the meta-analysis because they contributed to high heterogeneity. There is no clear difference in the incidence of thrombophlebitis whether catheters were changed according to clinical indication or routinely (RR 1.07, 95% CI 0.93 to 1.25; clinically indicated 317/3590; 3-day change 307/3733, moderate-certainty evidence, downgraded once for serious risk of bias). The result was unaffected by whether the infusion was continuous or intermittent. Six trials provided thrombophlebitis rates by number of device days (32,709 device days). There is no clear difference between groups (RR 0.90, 95% CI 0.76 to 1.08; clinically indicated 248/17,251; 3-day change 236/15,458; moderate-certainty evidence, downgraded once for serious risk of bias).One trial (3283 participants), assessed all-cause blood stream infection (BSI). We found no clear difference in the all-cause BSI rate between the two groups (RR 0.47, 95% CI 0.15 to 1.53; clinically indicated: 4/1593 (0.02%); routine change 9/1690 (0.05%); moderate-certainty evidence, downgraded one level for serious imprecision).Three trials (4244 participants), investigated costs; clinically indicated removal probably reduces device-related costs by approximately AUD 7.00 compared with routine removal (MD -6.96, 95% CI -9.05 to -4.86; moderate-certainty evidence, downgraded once for serious risk of bias).Secondary outcomesSix trials assessed infiltration (7123 participants). Routine replacement probably reduces infiltration of fluid into surrounding tissues compared with a clinically indicated change (RR 1.16 (95% CI 1.06 to 1.26; routine replacement 747/3638 (20.5%); clinically indicated 834/3485 (23.9%); moderate-certainty evidence, downgraded once for serious risk of bias).Meta-analysis of seven trials (7323 participants), found that rates of catheter failure due to blockage were probably lower in the routine-replacement group compared to the clinically indicated group (RR 1.14, 95% CI 1.01 to 1.29; routine-replacement 519/3733 (13.9%); clinically indicated 560/3590 (15.6%); moderate-certainty evidence, downgraded once for serious risk of bias).Four studies (4606 participants), reported local infection rates. It is uncertain if there are differences between groups (RR 4.96, 95% CI 0.24 to 102.98; clinically indicated 2/2260 (0.09%); routine replacement 0/2346 (0.0%); very low-certainty evidence, downgraded one level for serious risk of bias and two levels for very serious imprecision).One trial (3283 participants), found no clear difference in the incidence of mortality when clinically indicated removal was compared with routine removal (RR 1.06, 95% CI 0.27 to 4.23; low-certainty evidence, downgraded two levels for very serious imprecision).One small trial (198 participants) reported no clear difference in device-related pain between clinically indicated and routine removal groups (MD -0.60, 95% CI -1.44 to 0.24; low-certainty evidence, downgraded one level for serious risk of bias and one level for serious imprecision).The pre-planned outcomes 'number of catheter re-sites per patient', and 'satisfaction' were not reported by any studies included in this review.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence of no clear difference in rates of CRBSI, thrombophlebitis, all-cause BSI, mortality and pain between clinically indicated or routine replacement of PIVC. We are uncertain if local infection is reduced or increased when catheters are changed when clinically indicated. There is moderate-certainty evidence that infiltration and catheter blockage is probably lower when PIVC are changed routinely; and moderate-certainty evidence that clinically indicated removal probably reduces device-related costs. The addition of two new trials for this update found no further evidence to support changing catheters every 72 to 96 hours. Healthcare organisations may consider changing to a policy whereby catheters are changed only if there is a clinical indication to do so, for example, if there were signs of infection, blockage or infiltration. This would provide significant cost savings, spare patients the unnecessary pain of routine re-sites in the absence of clinical indications and would reduce time spent by busy clinicians on this intervention. To minimise PIVC-related complications, staff should inspect the insertion site at each shift change and remove the catheter if signs of inflammation, infiltration, occlusion, infection or blockage are present, or if the catheter is no longer needed for therapy.

Determining When It Is Safe to Remove the External Fixator: Results From a Survey of the Limb Lengthening and Reconstruction Society

Thousands of external fixators are applied for distraction osteogenesis each year. Determining when it is safe to remove the fixator can be difficult. The purpose of this study was to survey an international group of external fixation surgeons to determine their current practice patterns surrounding external fixator removal. A 10-question, open-ended survey was emailed to members of the Limb Lengthening and Reconstruction Society. Responses were recorded, and statistical analysis was performed. Pearson's chi-square test and likelihood ratio were used when indicated. A total of 124 surveys were sent, and 44 responses were received (35% response rate). The top 5 responses for determining when it is safe to remove a fixator were full weight bearing (75%), 3 cortices (71%), no pain (55%), after dynamization (55%), and duration of time (30%). Forty-eight percent of respondents routinely dynamized the frame prior to removal. Significantly fewer surgeons who dynamized the frame protected the limb after removal (P=.046). Physicians who dynamized the frame tended to use a less-constricting device for protection (boot or brace vs cast) than those who did not dynamize (P=.016). This study showed that most surgeons used radiographs and clinical evaluation to determine timing of fixator removal. Only 23% reported using computed tomography. Most surgeons dynamized the fixator prior to removal. Those who dynamized the frame were more confident in the regenerate healing. Although this study offers insight into what experienced surgeons do in their daily practice, it reveals many areas for improvement in the literature. [Orthopedics. 2017; 40(5):e876-e879.].

When to remove the urethral catheter after endoscopic realignment of traumatic disruption of the posterior urethra?

OBJECTIVE

To detect the optimal time for urethral stent removal after endoscopic urethral realignment and its effect on the incidence of development of urethral stricture.

PATIENTS AND METHODS

Eighteen patients underwent endoscopic urethral realignment after traumatic disruption of the posterior urethra. Post-operative urethroscopy was done using the flexible cystoscope to assess progress of urethral healing. The urethral Foley catheter that served as a stent and for urine drainage was removed only when complete mucosal healing was observed by flexible urethroscopy. There was a post-operative follow-up period of 12-36months. Uroflowmetry was performed at the end of the follow-up period.

RESULTS

Endoscopy 6weeks after realignment showed 50-75% mucosal epithelialization at the site of urethral disruption in all patients. Epithelialization was complete at 9weeks in 15/18 patients (83%) and at 12weeks in the remaining 3 patients (17%). One patient (5.6%) developed a mild symptomatic stricture 5months post stent removal that was successfully treated by a single session of visual urethrotomy. All 18 patients had normal uroflowmetry readings at 12-36months after realignment.

CONCLUSIONS

Urethral stenting should be continued till mucosal healing at the site of urethral disruption became complete. Removal of the stent at this optimal time decreases the incidence of post-operative urethral stricture. Flexible urethroscopy was a safe procedure for post-operative follow-up of endoscopic urethral realignment to assess the progress and completion of mucosal healing at the site of realignment.

LEVEL OF EVIDENCE

4.

A standardized surgical technique for removal of the Interstim tined lead

INTRODUCTION

Explantation of the Interstim sacral neuromodulation (SNM) device is occasionally necessary. Removing the tined lead can put strain on the lead, resulting in a possible break and retained fragments. The Food and Drug Administration (FDA) released a notification regarding health consequences related to retained lead fragments. We describe a novel and safe surgical technique for removing the Interstim device and permanent lead.

MATERIALS AND METHODS

We searched the Manufacturer and User Facility Device Experience (MAUDE) database for complications related to tined lead removal and searched the database of a single surgeon at our institution. Our standardized technique for tined lead removal is as follows. An incision is made over the previous lead insertion site and the lead is isolated and externalized. The fibrous encapsulation is dissected off the lead to expose the tines and ensure the lead is free from adhesions. The lead is removed by wrapping it around a curved hemostat and turning it under tension. If the lead breaks, the incision is extended and dissection is carried down to the sacral body to remove all fragments.

RESULTS

Twenty-eight patients had their tined lead removed between 2009 and 2015 after being in place a median of 2.00 years (IQR 1.32-3.32 years). One lead broke (3.6%) during removal over the 6 years using our standardized approach.

CONCLUSION

Permanent tined leads can break on removal and retained fragments can pose significant health consequences. Our technique standardizes the approach for removal and is safe and effective in our series.

Policies for replacing long-term indwelling urinary catheters in adults

BACKGROUND

Long-term indwelling catheters are used commonly in people with lower urinary tract problems in home, hospital and specialised health-care settings. There are many potential complications and adverse effects associated with long-term catheter use. The effect of health-care policies related to the replacement of long-term urinary catheters on patient outcomes is unclear.

OBJECTIVES

To determine the effectiveness of different policies for replacing long-term indwelling urinary catheters in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 19 May 2016), and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised controlled trials investigating policies for replacing long-term indwelling urinary catheters in adults were included.

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed data extraction and assessed risk of bias of all the included trials. Quality of evidence was assessed by adopting the GRADE approach. Any discrepancies were resolved by discussion between the review authors or an independent arbitrator. We contacted the authors of included trials to seek clarification where required.

MAIN RESULTS

Three trials met the inclusion criteria, with a total of 107 participants in three different health-care settings: A USA veterans administration nursing home; a geriatric centre in Israel; and a community nursing service in Hong Kong. Data were available for three of the pre-stated comparisons. Priefer and colleagues evaluated different time intervals between catheter replacement (n = 17); Firestein and colleagues evaluated the use of antibiotic prophylaxis at the time of replacement (n = 70); and Cheung and colleagues compared two different types of cleaning solutions (n = 20).All the included trials were small and under-powered. The reporting of the trials was inadequate and as a result, risk of bias assessment was judged to be unclear for the majority of the domains in two out of the three trials. There was insufficient evidence to indicate that (i) there was a lower incidence of symptomatic UTI in people whose catheter was changed both monthly and when clinically indicated (risk ratio (RR) 0.35, 95% confidence interval (CI) 0.13 to 0.95; very low quality evidence) compared to only when clinically indicated, (ii) there was not enough evidence to assess the effect of antibiotic prophylaxis on reducing: positive urine cultures at 7 days (RR 0.91, 95% CI 0.79 to 1.04); infection (RR 1.41, 95% CI 0.55 to 3.65); or death (RR 2.12, 95% CI 0.20 to 22.30; very low quality evidence), (iii) there was no statistically significant difference in the incidence of asymptomatic bacteruria at 7 days (RR 0.80, 95% CI 0.42 to 1.52) between people receiving water or chlorhexidine solution for periurethral cleansing at the time of catheter replacement. However, none of the 16 participants developed a symptomatic catheter-associated urinary tract infection (CAUTI) at day 14.The following outcomes were considered critical for decision-making and were also selected for the 'Summary of findings' table: (i) participant satisfaction, (ii) condition-specific quality of life, (iii) urinary tract trauma, and (iv) formal economic analysis. However, none of the trials reported these outcomes.None of the trials compared the following comparisons: (i) replacing catheter versus other policy e.g. washouts, (ii) replacing in the home environment versus clinical environment, (iii) clean versus aseptic technique for replacing catheter, (iv) lubricant A versus lubricant B or no lubricant, and (v) catheter user versus carer versus health professional performing the catheter replacement procedure.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to assess the value of different policies for replacing long-term urinary catheters on patient outcomes. In particular, there are a number of policies for which there are currently no trial data; and a number of important outcomes which have not been assessed, including patient satisfaction, quality of life, urinary tract trauma, and economic outcomes. There is an immediate need for rigorous, adequately powered randomised controlled trials which assess important clinical outcomes and abide by the principles and recommendations of the CONSORT statement.

Early removal versus expectant management of central venous catheters in neonates with bloodstream infection

BACKGROUND

Uncertainty exists regarding the management of newborn infants with a bloodstream infection and a central venous catheter in place. The central venous catheter may act as a nidus for infecting organisms and observational studies have suggested that early removal of the catheter is associated with a lower incidence of persistent or complicated infection. However, since central venous catheters provide secure vascular access to deliver nutrition and medications, the possible harms of early removal versus expectant management also need to be considered.

OBJECTIVES

To determine the effect of early removal versus expectant management of central venous catheters on morbidity and mortality in newborn infants with bloodstream infections.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 11), MEDLINE (1966 to October 2015), EMBASE (1980 to October 2015), CINAHL (1982 to October 2015), conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared early removal versus expectant management of central venous catheters in neonates with bloodstream infections.

DATA COLLECTION AND ANALYSIS

We used the standard methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

We did not identify any eligible randomised controlled trials.

AUTHORS' CONCLUSIONS

There are no trial data to guide practice regarding early removal versus expectant management of central venous catheters in newborn infants with bloodstream infections. A simple and pragmatic randomised controlled trial is needed to resolve the uncertainty about optimal management in this common and important clinical scenario.

Clinically-indicated replacement versus routine replacement of peripheral venous catheters

BACKGROUND

US Centers for Disease Control guidelines recommend replacement of peripheral intravenous (IV) catheters no more frequently than every 72 to 96 hours. Routine replacement is thought to reduce the risk of phlebitis and bloodstream infection. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation. Costs associated with routine replacement may be considerable. This is an update of a review first published in 2010.

OBJECTIVES

To assess the effects of removing peripheral IV catheters when clinically indicated compared with removing and re-siting the catheter routinely.

SEARCH METHODS

For this update the Cochrane Vascular Trials Search Co-ordinator searched the Cochrane Vascular Specialised Register (March 2015) and CENTRAL (2015, Issue 3). We also searched clinical trials registries (April 2015).

SELECTION CRITERIA

Randomised controlled trials that compared routine removal of peripheral IV catheters with removal only when clinically indicated in hospitalised or community dwelling patients receiving continuous or intermittent infusions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Seven trials with a total of 4895 patients were included in the review. The quality of the evidence was high for most outcomes but was downgraded to moderate for the outcome catheter-related bloodstream infection (CRBSI). The downgrade was due to wide confidence intervals, which created a high level of uncertainty around the effect estimate. CRBSI was assessed in five trials (4806 patients). There was no significant between group difference in the CRBSI rate (clinically-indicated 1/2365; routine change 2/2441). The risk ratio (RR) was 0.61 (95% CI 0.08 to 4.68; P = 0.64). No difference in phlebitis rates was found whether catheters were changed according to clinical indications or routinely (clinically-indicated 186/2365; 3-day change 166/2441; RR 1.14, 95% CI 0.93 to 1.39). This result was unaffected by whether infusion through the catheter was continuous or intermittent. We also analysed the data by number of device days and again no differences between groups were observed (RR 1.03, 95% CI 0.84 to 1.27; P = 0.75). One trial assessed all-cause bloodstream infection. There was no difference in this outcome between the two groups (clinically-indicated 4/1593 (0.02%); routine change 9/1690 (0.05%); P = 0.21). Cannulation costs were lower by approximately AUD 7.00 in the clinically-indicated group (mean difference (MD) -6.96, 95% CI -9.05 to -4.86; P ≤ 0.00001).

AUTHORS' CONCLUSIONS

The review found no evidence to support changing catheters every 72 to 96 hours. Consequently, healthcare organisations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings and would spare patients the unnecessary pain of routine re-sites in the absence of clinical indications. To minimise peripheral catheter-related complications, the insertion site should be inspected at each shift change and the catheter removed if signs of inflammation, infiltration, or blockage are present.

Intravascular device administration sets: replacement after standard versus prolonged use in hospitalised patients-a study protocol for a randomised controlled trial (The RSVP Trial)

INTRODUCTION

Vascular access devices (VADs), such as peripheral or central venous catheters, are vital across all medical and surgical specialties. To allow therapy or haemodynamic monitoring, VADs frequently require administration sets (AS) composed of infusion tubing, fluid containers, pressure-monitoring transducers and/or burettes. While VADs are replaced only when necessary, AS are routinely replaced every 3-4 days in the belief that this reduces infectious complications. Strong evidence supports AS use up to 4 days, but there is less evidence for AS use beyond 4 days. AS replacement twice weekly increases hospital costs and workload.

METHODS AND ANALYSIS

This is a pragmatic, multicentre, randomised controlled trial (RCT) of equivalence design comparing AS replacement at 4 (control) versus 7 (experimental) days. Randomisation is stratified by site and device, centrally allocated and concealed until enrolment. 6554 adult/paediatric patients with a central venous catheter, peripherally inserted central catheter or peripheral arterial catheter will be enrolled over 4 years. The primary outcome is VAD-related bloodstream infection (BSI) and secondary outcomes are VAD colonisation, AS colonisation, all-cause BSI, all-cause mortality, number of AS per patient, VAD time in situ and costs. Relative incidence rates of VAD-BSI per 100 devices and hazard rates per 1000 device days (95% CIs) will summarise the impact of 7-day relative to 4-day AS use and test equivalence. Kaplan-Meier survival curves (with log rank Mantel-Cox test) will compare VAD-BSI over time. Appropriate parametric or non-parametric techniques will be used to compare secondary end points. p Values of <0.05 will be considered significant.

ETHICS AND DISSEMINATION

Relevant ethical approvals have been received. CONSORT Statement recommendations will be used to guide preparation of any publication. Results will be presented at relevant conferences and sent to the major organisations with clinical practice guidelines for VAD care.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trial Registry (ACTRN 12610000505000).

Understanding surgical residents' postoperative practices and barriers and enablers to the implementation of an Enhanced Recovery After Surgery (ERAS) Guideline

INTRODUCTION

An Enhanced Recovery after Surgery (ERAS) Clinical Practice Guideline (CPG) was developed at the University of Toronto. Before implementation, general surgery residents were surveyed to assess their current stated practices and their perceived barriers and enablers to early discharge.

METHODS

The survey, which consisted of 33 questions related to the postoperative management of patients undergoing laparoscopic colectomy (LAC), open colectomy (OC) and open low anterior resection (LAR), was distributed to all residents. Chi-square and Fisher exact tests were used to test differences. Open-ended questions were analyzed using content analysis.

RESULTS

Of 77 residents surveyed, 58 (75%) responded. Residents stated that a fluid diet would be ordered on POD#0 and regular diet on POD#1 by 67.9% and 49.1%, respectively, following LAC, and 50.0% and 25.9%, respectively, following OC. On POD#1, 89.3% expected patients to ambulate following LAC compared with 67.9% following OC. Residents indicated that urinary catheters would be removed on POD#1 by 87% following LAC and by 81.3% following OC, and by POD#3 by 89.1% following LAR. However, in patients with an epidural, approximately 50% of residents stated that they would wait until it was removed. Overall, 76.4% of residents agreed that an ERAS CPG should be adopted. Residents cited setting expectations, encouragement of early ambulation and feeding, and good pain control as enablers to early discharge. However, patient and family expectations, surgeon preferences, and beliefs of the health care team were mentioned as barriers to early discharge.

CONCLUSION

Residents have a reasonable approach to the management of patients who underwent LAC, but there are gaps that exist in their management, especially following OC and LAR. Although most residents agreed with the implementation of an ERAS CPG, barriers exist, and strategies aimed at ensuring adherence with the recommendations are required.

Cost-effectiveness analysis of clinically indicated versus routine replacement of peripheral intravenous catheters

BACKGROUND

Millions of peripheral intravenous catheters are used worldwide. The current guidelines recommend routine catheter replacement every 72-96 h. This practice requires increasing healthcare resource use. The clinically indicated catheter replacement strategy is proposed as an alternative.

OBJECTIVES

To assess the cost effectiveness of clinically indicated versus routine replacement of peripheral intravenous catheters.

METHODS

A cost-effectiveness analysis from the perspective of Queensland Health, Australia, was conducted alongside a randomized controlled trial. Adult patients with an intravenous catheter of expected use for longer than 4 days were randomly assigned to receive either clinically indicated replacement or third-day routine replacement. The primary outcome was phlebitis during catheterization or within 48 h after catheter removal. Resource use data were prospectively collected and valued (2010 prices). The incremental net monetary benefit was calculated with uncertainty characterized using bootstrap simulations. Additionally, value of information (VOI) and value of implementation analyses were performed.

RESULTS

The clinically indicated replacement strategy was associated with a cost saving per patient of AU$7.60 (95% confidence interval [CI] 4.96-10.62) and a non-significant difference in the phlebitis rate of 0.41% (95% CI -1.33 to 2.15). The incremental net monetary benefit was AU$7.60 (95% CI 4.96-10.62). The expected VOI was zero, whereas the expected value of perfect implementation of the clinically indicated replacement strategy was approximately AU$5 million over 5 years.

CONCLUSION

The clinically indicated catheter replacement strategy is cost saving compared with routine replacement. It is recommended that healthcare organizations consider changing to a policy whereby catheters are changed only if clinically indicated.

Optimal timing for intravascular administration set replacement

BACKGROUND

The tubing (administration set) attached to both venous and arterial catheters may contribute to bacteraemia and other infections. The rate of infection may be increased or decreased by routine replacement of administration sets. This review was originally published in 2005 and was updated in 2012.

OBJECTIVES

The objective of this review was to identify any relationship between the frequency with which administration sets are replaced and rates of microbial colonization, infection and death.

SEARCH METHODS

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6), MEDLINE (1950 to June 2012), CINAHL (1982 to June 2012), EMBASE (1980 to June 2012), reference lists of identified trials and bibliographies of published reviews. The original search was performed in February 2004. We also contacted researchers in the field. We applied no language restriction.

SELECTION CRITERIA

We included all randomized or controlled clinical trials on the frequency of venous or arterial catheter administration set replacement in hospitalized participants.

DATA COLLECTION AND ANALYSIS

Two review authors assessed all potentially relevant studies. We resolved disagreements between the two review authors by discussion with a third review author. We collected data for seven outcomes: catheter-related infection; infusate-related infection; infusate microbial colonization; catheter microbial colonization; all-cause bloodstream infection; mortality; and cost. We pooled results from studies that compared different frequencies of administration set replacement, for instance, we pooled studies that compared replacement ≥ every 96 hours versus every 72 hours with studies that compared replacement ≥ every 48 hours versus every 24 hours.

MAIN RESULTS

We identified 26 studies for this updated review, 10 of which we excluded; six did not fulfil the inclusion criteria and four did not report usable data. We extracted data from the remaining 18 references (16 studies) with 5001 participants: study designs included neonate and adult populations, arterial and venous administration sets, parenteral nutrition, lipid emulsions and crystalloid infusions. Most studies were at moderate to high risk of bias or did not adequately describe the methods that they used to minimize bias. All included trials were unable to blind personnel because of the nature of the intervention.No evidence was found for differences in catheter-related or infusate-related bacteraemia or fungaemia with more frequent administration set replacement overall or at any time interval comparison (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.67 to 1.69; RR 0.67, 95% CI 0.27 to 1.70). Infrequent administration set replacement reduced the rate of bloodstream infection (RR 0.73, 95% CI 0.54 to 0.98). No evidence revealed differences in catheter colonization or infusate colonization with more frequent administration set replacement (RR 1.08, 95% CI 0.94 to 1.24; RR 1.15, 95% CI 0.70 to 1.86, respectively). Borderline evidence suggested that infrequent administration set replacement increased the mortality rate only within the neonatal population (RR 1.84, 95% CI 1.00 to 3.36). No evidence revealed interactions between the (lack of) effects of frequency of administration set replacement and the subgroups analysed: parenteral nutrition and/or fat emulsions versus infusates not involving parenteral nutrition or fat emulsions; adult versus neonatal participants; and arterial versus venous catheters.

AUTHORS' CONCLUSIONS

Some evidence indicates that administration sets that do not contain lipids, blood or blood products may be left in place for intervals of up to 96 hours without increasing the risk of infection. Other evidence suggests that mortality increased within the neonatal population with infrequent administration set replacement. However, much the evidence obtained was derived from studies of low to moderate quality.

Clinically-indicated replacement versus routine replacement of peripheral venous catheters

BACKGROUND

US Centers for Disease Control guidelines recommend replacement of peripheral intravenous (IV) catheters no more frequently than every 72 to 96 hours. Routine replacement is thought to reduce the risk of phlebitis and bloodstream infection. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation. Costs associated with routine replacement may be considerable. This is an update of a review first published in 2010.

OBJECTIVES

To assess the effects of removing peripheral IV catheters when clinically indicated compared with removing and re-siting the catheter routinely.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases (PVD) Group Trials Search Co-ordinator searched the PVD Specialised Register (December 2012) and CENTRAL (2012, Issue 11). We also searched MEDLINE (last searched October 2012) and clinical trials registries.

SELECTION CRITERIA

Randomised controlled trials that compared routine removal of peripheral IV catheters with removal only when clinically indicated in hospitalised or community dwelling patients receiving continuous or intermittent infusions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Seven trials with a total of 4895 patients were included in the review. Catheter-related bloodstream infection (CRBSI) was assessed in five trials (4806 patients). There was no significant between group difference in the CRBSI rate (clinically-indicated 1/2365; routine change 2/2441). The risk ratio (RR) was 0.61 but the confidence interval (CI) was wide, creating uncertainty around the estimate (95% CI 0.08 to 4.68; P = 0.64). No difference in phlebitis rates was found whether catheters were changed according to clinical indications or routinely (clinically-indicated 186/2365; 3-day change 166/2441; RR 1.14, 95% CI 0.93 to 1.39). This result was unaffected by whether infusion through the catheter was continuous or intermittent. We also analysed the data by number of device days and again no differences between groups were observed (RR 1.03, 95% CI 0.84 to 1.27; P = 0.75). One trial assessed all-cause bloodstream infection. There was no difference in this outcome between the two groups (clinically-indicated 4/1593 (0.02%); routine change 9/1690 (0.05%); P = 0.21). Cannulation costs were lower by approximately AUD 7.00 in the clinically-indicated group (mean difference (MD) -6.96, 95% CI -9.05 to -4.86; P ≤ 0.00001).

AUTHORS' CONCLUSIONS

The review found no evidence to support changing catheters every 72 to 96 hours. Consequently, healthcare organisations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings and would spare patients the unnecessary pain of routine re-sites in the absence of clinical indications. To minimise peripheral catheter-related complications, the insertion site should be inspected at each shift change and the catheter removed if signs of inflammation, infiltration, or blockage are present.

Inadequate follow-up after tracheostomy and intensive care

INTRODUCTION

When patients are transferred from intensive care units (ICUs) to general wards with a tracheostomy in situ, there is a risk of suboptimal care and increased morbidity. The aim of this study was to elucidate the management of patients with a tracheostomy in situ at discharge from the ICU to the ward.

MATERIAL AND METHODS

We performed an electronic questionnaire survey among heads of unit at registered Danish ICUs.

RESULTS

A total of 34 out of 43 ICUs responded. 56% of the ICUs do not document individual plans for decannulation in the patient's chart. 91% of the ICUs do not perform daily follow-up of tracheotomised patients on the ward. No guidelines for decannulation on the ward were found, and only 6% have a guideline for accidental decannulation. Furthermore, as little as 47% of the ICUs report any formalized education or training of staff nurses in the management of tracheotomised patients.

CONCLUSION

Guidelines relevant to patients discharged from Danish ICUs with a tracheal cannula in situ are scarce; few ICUs employ individualized plans for tracheostomy management and decannulation; there is largely no daily intensivist-led post-ICU follow-up, and formal staff education in tracheostomy management on the ward is scarce. Altogether these factors create a potential for adverse events and increased morbidity in this high-risk, high-cost patient population. Possibly individualized plans for tracheotomised patients as well as intensivist-led follow-up on the ward can improve patient outcome and safety and this should be confirmed in a future study.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

[Recommendations of the Working Group of Arrhythmias of the German Society of Cardiology on the approach to patients with Riata® and Riata ST® leads (St. Jude Medical). Nucleus of the Working Group of Arrhythmias of the German Society of Cardiology]

Riata® and Riata ST® implantable cardioverter defibrillator (ICD) leads (St. Jude Medical, Sylmar, CA) show an increased incidence of insulation defects, particularly "inside-out" lead fracture where inner, separately insulated cables penetrate through the surrounding silicone of the lead body. The exact incidence of Riata® lead problems is not clear and seems to range between 2-4% per year in the first 5 years after implantation according to new registry data. We recommend beyond a detailed information the following care of patients with Riata® and Riata ST® leads: 1) Activation of automatic ICD alerts, 2) remote monitoring with automatic daily alerts whenever possible, 3) monthly ICD controls in patients at high risk (pacemaker dependency, history of ventricular tachyarrhythmias) and high or moderate lead-related risk (8F, 7F single coil), 3-monthly controls in moderate patient and lead-related risk, 3 to 6-monthly controls in low patient and lead-related risk (no bradycardia, no history of ventricular tachyarrhythmia). Every ICD control should include meticulous analysis of oversensing artifacts in stored electrograms (EGMs) of sustained and non-sustained ventricular tachyarrhythmias and registration of EGMs during provocation testing (pectoral muscle activity, arm movements). If electrical abnormalities are observed, reoperation with addition of a new ICD lead is recommended; lead extraction only if indicated according to current guidelines. Fluoroscopy should only be performed if electrical abnormalities are found by an experienced electrophysiologist and a high frame rate and resolution. Management of fluoroscopic abnormalities in the absence of electrical abnormalities is not clear. Therefore, routine fluoroscopy of patients with Riata® leads without electrical abnormalities is not recommended.

Early removal versus expectant management of central venous catheters in neonates with bloodstream infection

BACKGROUND

Uncertainty exists regarding the management of central venous catheters (CVCs) in neonates with bloodstream infections. Early CVC removal may reduce the risk of persistent or complicated infection and its associated morbidity and mortality. However, since CVCs provide secure vascular access to deliver nutrition and medications, the possible harms of early removal versus expectant management need to be considered.

OBJECTIVES

To determine the effect of early removal versus expectant management of CVCs on morbidity and mortality in neonates with bloodstream infections..

SEARCH STRATEGY

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials ((CENTRAL), The Cochrane Library, 2011, Issue 1), MEDLINE (1966 to January 2011), EMBASE (1980 to January 2011), CINAHL (1982 to January 2011), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared early removal versus expectant management of CVCs in neonates with bloodstream infections.

DATA COLLECTION AND ANALYSIS

We used the standard methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

We did not identify any eligible randomised controlled trials.

AUTHORS' CONCLUSIONS

There are no trial data to guide practice regarding early removal versus expectant management of CVCs in neonates with bloodstream infections. While observational data generally indicate that early removal is associated with a lower incidence of persistent or complicated infection, caution should be exercised in applying these findings to practice because of inherent biases in the study design. A simple and pragmatic randomised controlled trial is needed to resolve the uncertainty about optimal management in this common and important clinical scenario.

Percutaneous retrieval of an interatrial septal occluder device embolized into the aortic arch

Percutaneous closure of secundum atrial septal defects (ASD) may be complicated by immediate embolization. We report on a 35-year-old woman who underwent percutaneous device closure for a secundum ASD. The diameter of the defect was measured as 4 mm by two-dimensional transesophageal echocardiography and a 7-mm Figulla ASD occluder device was implanted without prior balloon sizing of the defect. Immediate embolization was noted into the aortic arch. Attempts to pull the devices into the sheath with a loop snare failed even after replacing the delivery sheath with a bigger one. Finally, a bioptome was used to grab and place the screw mechanisms in the sheath and percutaneous retrieval of the embolized ASD occluder was achieved. Balloon sizing was performed after removal, yielding a stretched diameter of 12 mm and a 15-mm device was deployed with success.

Clinically-indicated replacement versus routine replacement of peripheral venous catheters

BACKGROUND

Centers for Disease Control Guidelines recommend replacement of peripheral intravenous (IV) catheters every 72 to 96 hours. Routine replacement is thought to reduce the risk of phlebitis and bacteraemia. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation. Costs associated with routine replacement may be considerable.

OBJECTIVES

To assess the effects of removing peripheral IV catheters when clinically indicated compared with removing and re-siting the catheter routinely.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched October 2009) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue Issue 4, 2009). We also searched MEDLINE (last searched October 2009).

SELECTION CRITERIA

Randomised controlled trials that compared routine removal of peripheral IV catheters with removal only when clinically indicated in hospitalised or community dwelling patients receiving continuous or intermittent infusions.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality and extracted data.

MAIN RESULTS

In five trials (3408 participants) there was a 44% reduction in suspected catheter-related bacteraemia in the clinically-indicated group (0.2 versus 0.4%) but this was not statistically significant (odds ratio (OR) 0.57; 95% confidence interval (CI) 0.17 to 1.94; P = 0.37). Phlebitis was assessed in six trials (3455 patients); there was a non-significant increase in phlebitis in the clinically-indicated group (9% versus 7.2%); the OR was 1.24 (95% CI 0.97 to 1.60; P = 0.09). We also measured phlebitis per 1000 device days using data from five trials, (8779 device days). No statistical differences in the incidence of phlebitis per 1,000 device days was found (clinically indicated 1.6 cases per 1,000 catheter days versus 1.5 cases per 1,000 catheter days in the routine-replacement group).The combined OR was 1.04 (95% CI 0.81 to 1.32; P = 0.77). Cost was measured in two trials (961 patients). Cannulation costs were significantly reduced in the clinically-indicated group (mean difference (MD) -6.21; 95% CI -9.32 to -3.11; P = < 0.000).

AUTHORS' CONCLUSIONS

The review found no conclusive evidence of benefit in changing catheters every 72 to 96 hours. Consequently, health care organisations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings and would also be welcomed by patients, who would be spared the unnecessary pain of routine re-sites in the absence of clinical indications.

[Indications for the procedure for transvenous removing of electrodes based on the guidelines of U.S. societies]

The number of implanted the cardiovascular implantable electronic device(s) (CIED(s))--pacemakers (PM) and implantable cardioverters defibrillators (ICD)--increases each year. The number of CIED(s) exchange procedures as well as changes in models of stimulation (upgrade to dual chamber pacemakers or three chamber cardiac resynchronization therapy devices) also grows. Also increases the inactive electrode left in the cardiovascular system. The risk of infection is higher during the exchange of devices than with their implantation. Treatments for patients with multiple electrode systems are becoming a potential source of infection. The incidence of damage defibrillator is greater than pacemaker leads. Intracardiac electrodes causes the growth of connective tissue, fibrosis in the venous system and may cause obstruction subclavian vein or brachiocephalic preventing implantation needed a new electrode. Damaged and broken electrodes may migrate to the cavities of the heart. This increases the risk of thrombosis, pulmonary embolism, tricuspid valve dysfunction and serious arrhythmias. All these facts presented lead to the conclusion that the growing need to remove the electrodes (both infected and inactive) pacemaker or cardioverter defibrillator. There are two classes of indications to remove the electrodes. Procedures for removing the benefits must outweigh the risks. Should be considered for each patient individually and take into account the experience of the operator and its results. Class I indications are: lead dependent endocarditis, sepsis, arrhythmias or embolism secondary to the presence of lead, venous occlusion prevents the implantation of new electrodes, interference between the electrodes, an implantable device infection box. Class II includes: chronic pain in the area and inactive pacemaker electrodes in young people. After removal must be individually examined whether there is a need to implant the new layout. It should not be implanted in a place that has previously been infected. The preferred area is the opposite, iliac vein, reaching epicardial implantation.

Can outcomes of intensive care unit patients undergoing tracheostomy be predicted?

OBJECTIVE

To determine whether outcomes (mortality and need for intensive care unit [ICU] readmission) of patients undergoing tracheostomy in the ICU can be predicted by common clinical or historical criteria.

METHODS

We conducted a retrospective review of data from the medical record and Project Impact database in a 24-bed medical-surgical ICU in a 500-bed university hospital. In 2004 through 2006, 60 adult patients underwent tracheostomy as part of their ICU management. We classified each patient as either not readmitted, readmitted, died on floor (after ICU discharge), died on first ICU admission, or combined readmitted/died-on-the-floor. Patients who died on the regular floor were significantly heavier than patients discharged without need for readmission (P = .03). Patients with a history of sepsis and those with a history of neurological disease had a tendency toward worse outcomes, but these did not reach statistical significance.

CONCLUSIONS

These findings suggest that it is difficult to predict outcomes of patients who undergo tracheostomy in the ICU. Larger and prospective studies may help elucidate this matter.

Tracheostomy tube in place at intensive care unit discharge is associated with increased ward mortality

OBJECTIVE

To determine the relationship between tracheostomy tube in place after intensive-care-unit (ICU) discharge and hospital mortality.

METHODS

We conducted a prospective observational cohort study in a medical-surgical ICU in a tertiary-care hospital that does not have a step-down unit. We recorded clinical and epidemiologic variables, indication and timing of tracheostomy, time to decannulation, characteristics of respiratory secretions, need for suctioning, and Glasgow coma score at ICU discharge. We excluded patients who had do-not-resuscitate orders, tracheostomy for long-term airway control, neuromuscular disease, or neurological damage.

RESULTS

A total of 118 patients were tracheostomized in the ICU, and 73 were discharged to the ward without neurological damage. Of these, 35 had been decannulated. Ward mortality was 19% overall, 11% in decannulated patients, and 26% in patients with the tracheostomy tube in place; that difference was not statistically significant in the univariate analysis (P = .10). However, the multivariate analysis, which adjusted for lack of decannulation, age, sex, body mass index, severity of illness, diagnosis at ICU admission, duration of mechanical ventilation, Glasgow coma score, characteristics of respiratory secretions, and need for suctioning at ICU discharge, found 3 factors associated with ward mortality: lack of decannulation at ICU discharge (odds ratio 6.76, 95% confidence interval 1.21-38.46, P = .03), body mass index > 30 kg/m(2) (odds ratio 5.81, 95% confidence interval 1.24-27.24, P = .03), and tenacious sputum at ICU discharge (odds ratio 7.27, 95% confidence interval 1-55.46, P = .05).

CONCLUSIONS

In our critical-care setting, lack of decannulation of conscious tracheostomized patients before ICU discharge to the general ward was associated with higher mortality.

A North American survey of respiratory therapist and physician tracheostomy decannulation practices

BACKGROUND

Tracheostomy is a common surgical procedure performed on critically ill patients. However, little is known about how clinicians make decisions to decannulate patients, and whether similar decisions are made by respiratory therapists (RTs) and physicians.

METHODS

We performed a cross-sectional survey of RTs (n = 52) and physicians (n = 102) at 54 medical centers in North America, to characterize contemporary decannulation practices.

RESULTS

RTs and physicians rated ability to tolerate capping, secretions, cough effectiveness, and level of consciousness as the most important factors in the decannulation decision, with RTs placing greater emphasis on ability to tolerate capping and physicians on level of consciousness. In the clinical scenarios, RTs and physicians recommended decannulation with similar frequency (52% vs 55%, P = .54). Patients were most likely to be recommended for decannulation if they had a strong cough, scant thin secretions, required minimal supplemental oxygen, and were alert and interactive. In addition, RTs were more likely to recommend decannulation for patients who demonstrated an ability to tolerate tracheostomy tube capping for 72 hours and whose etiology of respiratory failure was chronic obstructive pulmonary disease. RTs preferred shorter time frames for defining decannulation failure than did physicians (median response 48 h vs 96 h, P = .02 for test of proportions). Both groups identified 2-5% (median response) as an acceptable rate of decannulation failure (P = .48 for test of proportions).

CONCLUSIONS

Important differences exist in the decannulation practices of North American RTs and physicians. Evidence-based tracheostomy guidelines are needed to facilitate the safe and effective management of patients with tracheostomies.

[Reasons and complications of pacemaker replacement operation: clinical analysis of 69 case-times]

OBJECTIVE

To analyze the reasons of cardiac permanent pacemaker replacement and the strategies to prevent relevant complications.

METHODS

The clinical data of 57 patients, 38 males and 19 females, aged 74 +/- 8 (56-94), 31 with sick sinus syndrome, 26 with II or III degree atrioventricular block, who underwent 63 times of cardiac permanent pacemaker replacement, including 13 times of lead replacement, were analyzed.

RESULTS

The reason of replacement included battery normal exhaustion for 57 case-times, battery exhaustion before the defined schedule for 2 case-times, lead electrodes incompletely fractured for 2 case-times, and infection of pacemaker pocket for 2 case-times. There were 9 cases of placement-related complications: pacemaker pocket hematoma (n=4), lead dislocation (n=3), and abandoned leads falling into the right ventricle (n=2). The average lifetime of old pacemakers was 9. 25 years (2 -15 years). The pacing threshold of ventricular leads after pacemaker replacement was (0.77 +/- 0. 40)V, significantly higher than the initial pacing threshold [(0.60 +/- 0.21)V, P < 0.01]. There were no significant differences in the lead impedance and R wave amplitude between the pacemaker replacement and initial implantation [(854 +/- 136)omega vs. (828 +/- 176)omega, and (12 +/- 4)mV vs. (12 +/- 4)mV, both P > 0.05].

CONCLUSION

The main reason of pacemaker replacement is battery exhaustion. Most implanted ventricular leads still can be used. A rare serious complication of cardiac pacemaker replacement operation is abandoned lead falling into the right ventricle, and correct disposing of initial leads help avoid this complication .

The forgotten ureteric JJ stent and its prevention: a prospective audit of the value of a ureteric stent logbook

BACKGROUND

Temporary ureteric stent insertion is an integral part of modern endo-urological practice. Delayed stent removal or forgotten stents are associated with increased patient morbidity and complications which are often difficult to manage.

METHODS AND RESULTS

We prospectively audited our ureteric stent insertion and removal logbook system to determine the value and effectiveness of our stent follow-up. Over a 1-year period, 210 ureteric stents were inserted in our urological unit. Of these, 47 (22.4%) patients were unaccounted as having their stents removed within the stent logbooks. One patient was lost to follow-up and re-presented with stent encrustation 10 months later.

CONCLUSIONS

Our results in this audit suggest that our system of ureteric stent follow-up is not effective. We have now introduced a new system that we feel is a safer and a satisfactory alternative to the stent logbooks. This includes a patient education leaflet and removal date scheduling prior to discharge from hospital.

Strategies for the removal of short-term indwelling urethral catheters in adults

BACKGROUND

Approximately 15% to 25% of all hospitalised patients have indwelling urethral catheters, mainly to assist clinicians to accurately monitor urine output during acute illness or following surgery, to treat urinary retention, and for investigative purposes.

OBJECTIVES

The objective of this review was to determine the best strategies for the removal of catheters from patients with a short-term indwelling urethral catheter. The main outcome of interest was the number of patients who required recatheterisation following removal of indwelling urethral catheter.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 7 December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2), MEDLINE (January 1966 to 12 July 2006), EMBASE (January 1980 to 12 July 2006), CINAHL (January 1982 to 12 July 2006), Nursing Collection (January 1995 to January 2002) and reference lists of relevant articles and conference proceedings were searched. We also contacted manufacturers and researchers in the field. No language or other restrictions were applied.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials (RCTs) that compared the effects of alternative strategies for removal of short-term indwelling urethral catheters on patient outcomes were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials were assessed independently by two reviewers. Relative risks (RR) for dichotomous data and a weighted mean difference (WMD) for continuous data were calculated with 95% confidence intervals (CI). Where synthesis was inappropriate, trials were considered separately.

MAIN RESULTS

Twenty six trials involving a total of 2933 participants were included in the review. One trial included three treatment groups. In 11 RCTs amongst 1389 people, there was no significant difference in need for recatheterisation, although recatheterisation after removal at night was more likely to be during working hours. Pooled results demonstrated that, following urological surgery and procedures, patients whose indwelling urethral catheters were removed at midnight passed significantly larger volumes at their first void (Difference (fixed) 96 ml; 95% CI 62 to 130). Similar findings were reported for patients following TURP (Difference (fixed) 27; 95% CI 23 to 31). Removal at midnight was also associated with longer time to first void, and shorter lengths of hospitalisation (relative risk of not going home on day of removal = 0.71, 95% CI 0.64 to 0.79). Results in 13 trials amongst 1422 participants having early rather than delayed catheter removal were consistent with a higher risk of voiding problems and a lower risk of infection, with shorter hospitalisation. In three trials involving 234 participants the data were too few to assess differential effects of catheter clamping compared with free drainage prior to withdrawal. No eligible trials compared flexible with fixed duration of catheterisation, or assessed prophylactic alpha sympathetic blocker drugs prior to catheter removal.

AUTHORS' CONCLUSIONS

There is suggestive but inconclusive evidence of a benefit from midnight removal of the indwelling urethral catheter. There are resource implications but the magnitude of these is not clear from the trials. The evidence also suggests shorter hospital stay after early rather than delayed catheter removal but the effects on other outcomes are unclear. There is little evidence on which to judge other aspects of management, such as catheter clamping.

Decannulation in children after long-term tracheostomy

Various approaches and techniques are used in discontinuing tracheostomy in children. The variability in the use of resources is considerable. The objective of the study was to assess decannulation in children attending our ENT department. A retrospective analysis was carried out of the medical records of patients who had had both a tracheostomy (n=7) and a decannulation (n=6) from 1998 to 2003. Tracheostomies placed at a mean age of 4.2 months were discontinued on average 26.4 months later. All the children underwent airway endoscopy in the operating room in preparation for decannulation. They had downsizing, then capping of the tracheostomy as a functional trial. One child failed decannulation and another needed a second trial for successful decannulation. The individualization of tracheostomy decannulation is necessary in children.

Optimal timing for intravenous administration set replacement

BACKGROUND

Administration of intravenous therapy is a common occurrence within the hospital setting. Routine replacement of administration sets has been advocated to reduce intravenous infusion contamination. If decreasing the frequency of changing intravenous administration sets does not increase infection rates, a change in practice could result in considerable cost savings.

OBJECTIVES

The objective of this review was to identify the optimal interval for the routine replacement of intravenous administration sets when infusate or parenteral nutrition (lipid and non-lipid) solutions are administered to people in hospital via central or peripheral venous catheters.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, EMBASE: all from inception to February 2004; reference lists of identified trials, and bibliographies of published reviews. We also contacted researchers in the field. We did not have a language restriction.

SELECTION CRITERIA

We included all randomized or quasi-randomized controlled trials addressing the frequency of replacing intravenous administration sets when parenteral nutrition (lipid and non-lipid containing solutions) or infusions (excluding blood) were administered to people in hospital via a central or peripheral catheter.

DATA COLLECTION AND ANALYSIS

Two authors assessed all potentially relevant studies. We resolved disagreements between the two authors by discussion with a third author. We collected data for the outcomes; infusate contamination; infusate-related bloodstream infection; catheter contamination; catheter-related bloodstream infection; all-cause bloodstream infection and all-cause mortality.

MAIN RESULTS

We identified 23 references for review. We excluded eight of these studies; five because they did not fit the inclusion criteria and three because of inadequate data. We extracted data from the remaining 15 references (13 studies) with 4783 participants. We conclude that there is no evidence that changing intravenous administration sets more often than every 96 hours reduces the incidence of bloodstream infection. We do not know whether changing administration sets less often than every 96 hours affects the incidence of infection. In addition, we found that there were no differences between participants with central versus peripheral catheters; nor between participants who did and did not receive parenteral nutrition, or between children and adults.

AUTHORS' CONCLUSIONS

It appears that administration sets that do not contain lipids, blood or blood products may be left in place for intervals of up to 96 hours without increasing the incidence of infection. There was no evidence to suggest that administration sets which contain lipids should not be changed every 24 hours as currently recommended.

Surgical indications and outcomes of tympanostomy tube removal

OBJECTIVE

To evaluate factors affecting perforation healing in children with surgical removal of retained tympanostomy tubes.

METHODS

We conducted a retrospective chart review of 82 pediatric patients (111 ears) who underwent surgical tube removal at a tertiary care pediatric hospital from 1/1/1999 to 12/31/2001. Patients included 47 males and 35 females with an age range of 2-15 years (average age, 6.8 years and median, 6 years). The length of intubation ranged from 12 months to 108 months (average, 44.6 months). The indications for removal included: prolonged intubation (61.3%), otorrhea or recurrent infection (21.6%), obstruction (7.2%), tube in middle ear (6.3%), enlarging perforation (2.7%), and in preparation for future cochlear implant surgery (9.9%). Interventions included removal of tympanostomy tubes and techniques for encouraging perforation closure. Seventy-six percent of the ears had a technique used to encourage healing. These techniques included freshen edges (11.8%), Gelfoam or Gelfilm (14.1%), Gelfoam and/or Gelfilm with freshened edges (50.6%). The main outcome measure was perforation healing. Chi-square statistical analysis were used to determine the statistical significant of observations.

RESULTS

Overall closure rate for all patients available for follow up was 87.0%, regardless of technique used to encourage healing. There was no statistically significant difference between the average intubation time in ears that healed (44 months), versus those with persistent perforation after removal (42 months). There was no statistical significant difference in closure rate based on patient age. When tubes were removed for prolonged intubation, 87.0% closed. If the indication was otorrhea or recurrent infections, 93.0% healed.

CONCLUSIONS

The overwhelming majority of patients who undergo surgical removal of tubes will show complete tympanic membrane healing independent of technique at time of removal, duration of intubation, patient age, or indication for removal.

Tracheostomy decannulation

The respiratory therapist plays an integral role in tracheostomy tube decannulation. Removal of the tracheostomy tube should be considered only if the original upper-airway obstruction is resolved, if airway secretions are controlled, and if mechanical ventilation is no longer needed. Predictors of success include ability to produce a vigorous cough and the absence of aspiration. Tracheostomy decannulation requires caution, particularly following a prolonged period of tracheostomy use. The tracheostomy tube decannulation process is well suited for therapist-implemented protocols.

Policies for the removal of short-term indwelling urethral catheters

BACKGROUND

Approximately 15% to 25% of all hospitalised patients have indwelling urethral catheters, mainly to assist clinicians to accurately monitor urine output during acute illness or following surgery, to treat urinary retention, and for investigative purposes.

OBJECTIVES

The objective of this review was to determine the best strategies for the removal of catheters from patients with a short-term indwelling urethral catheter.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised register (searched 16 December 2002), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2004), MEDLINE (January 1966 to 12 October 2004), EMBASE (January 1980 to 12 October 2004), CINAHL (January 1982 to 12 October 2004), Nursing Collection (January 1995 to January 2002) and reference lists of relevant articles and conference proceedings were searched. We also contacted manufacturers and researchers in the field. No language or other restrictions were applied.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials (RCTs) that compared the effects of alternative strategies for removal of short-term indwelling urethral catheters on patient outcomes were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials were assessed independently by two reviewers. Relative risks (RR) for dichotomous data and a weighted mean difference (WMD) for continuous data were calculated with 95% confidence intervals (CI). Where synthesis was inappropriate, trials were considered separately.

MAIN RESULTS

Eighteen trials involving a total of 1964 participants were included in the review. One trial included three treatment groups. In eight RCTs amongst 1020 people, removal at midnight was associated with large volumes of urine at first void, longer times to first void, and shorter lengths of hospitalisation. There was no significant difference in need for recatheterisation, although recatheterisation after removal at night was more likely to be during working hours. In eight trials amongst 822 participants early rather than delayed catheter removal was associated with shorter hospitalisation, but the estimates of other differences were all imprecise. In three trials involving 234 participants the data were too few to assess differential effects of catheter clamping compared with free drainage prior to withdrawal. No eligible trials compared flexible with fixed duration of catheterisation, or assessed prophylactic alpha sympathetic blocker drugs prior to catheter removal.

AUTHORS' CONCLUSIONS

There is suggestive but inconclusive evidence of a benefit from midnight removal of the indwelling urethral catheter. There are resource implications but the magnitude of these is not clear from the trials. The evidence also suggests shorter hospital stay after early rather than delayed catheter removal but the effects on other outcomes are unclear. There is little evidence on which to judge other aspects of management, such as catheter clamping.

Urethral catheter removal 7 or 14 days after radical retropubic prostatectomy: clinical implications and complications in a randomized study

PURPOSE

To evaluate the hypothesis that a 7-day period of indwelling catheter after radical retropubic prostatectomy is effective and safe without the need of performing cystography.

METHODS

In the period from January of 2000 to July of 2002, 73 patients underwent radical retropubic prostatectomy, and these patients were prospectively randomized in 2 groups: Group 1-37 patients who had the urethral catheter removed 7 days after the procedure, and Group 2-36 patients who had the catheter removed 14 days after the surgery. The 2 groups were similar, the surgeons and the technique were the same, and no cystography was performed to evaluate the presence of leaks.

RESULTS

Two patients in Group 1 had bleeding and clot retention after having the catheter taken out in the seventh postoperative day and were managed by putting the catheter back in for 7 more days. Two patients in Group 2 developed bladder neck stricture and were treated by bladder neck incision with success. The continence rate was the same, with 2 cases of incontinence in each group. About 2 pads a day were used by the patients with incontinence. The average follow-up was 17.5 months (12-36 months). No urinary fistula, urinoma, or pelvic abscesses developed after catheter removal. Two patients were excluded from the analysis of this series: 1 died with a pulmonary embolus in the third postoperative day, and 1 developed a urinary suprapubic fistula before catheter withdrawal, which was maintained for 16 days.

CONCLUSION

Withdrawal of the urethral catheter 7 days after radical retropubic prostatectomy, without performing cystography, has a low rate of short-term complications that are equivalent to withdrawal 14 days after the surgery.

Phlebitis rate and time kinetics of short peripheral intravenous catheters

BACKGROUND

An observational prospective cohort study was carried out on complication rates and time kinetics of phlebitis caused by short peripheral intravenous catheters (PIVCs) in inpatients on 15 hospital wards in four hospitals in Cologne, Germany.

PATIENTS AND METHODS

We observed 1,582 patients with 2,495 PIVCs daily using standardized questionnaires. Phlebitis was defined using modified Centers for Disease Control and Prevention (CDC) criteria.

RESULTS

Average phlebitis rates were 27 per 100 patients and 104 per 1,000 catheter days. Median duration of PIVC was 2 days (25 percentile = 2 days; 75 percentile 3 days). Time kinetics (Kaplan-Meier) were linear.

CONCLUSION

Linear time kinetics of PIVC phlebitis do not support CDC recommendations for an elective PIVC change after 72 hours, provided daily monitoring of the insertion site occurs.