A multicentre snapshot study of the incidence of serious procedural complications secondary to central venous catheterisation

Despite the high number of central venous access devices inserted annually, there are limited data on the incidence of the associated procedural complications, many of which carry substantial clinical risk. This point was highlighted in the recently published Association of Anaesthetists of Great Britain and Ireland ‘Safe vascular access 2016’ guidelines. This trainee‐led snapshot study aimed to identify the number of central venous catheter insertions and the incidence of serious complications across multiple hospital sites within a fixed two‐week period. Secondary aims were to identify the availability of resources and infrastructure to facilitate safe central venous catheter insertion and management of potential complications. Fifteen hospital sites participated, completing an initial resource survey and daily identification of all adult central venous catheter insertions, with subsequent review of any complications detected. A total of 487 central venous catheter insertions were identified, of which 15 (3.1%) were associated with a significant procedural complication. The most common complication was failure of insertion, which occurred in seven (1.4%) cases. Facilities to enable safer central venous catheter insertion and manage complications varied widely between hospitals, with little evidence of standardisation of guidelines or protocols.     

Impact of faculty-specific electronic reminders on faculty compliance with daily resident evaluations: a retrospective study

Study ObjectiveTo assess the effectiveness of faculty-specific electronic reminders on increasing faculty compliance with completing daily anesthesia resident evaluations.DesignRetrospective study.SettingAnesthesiology Residency Program at Oregon Health & Science University.Measurements41 faculty members on staff from February 2004 through January 2006 were studied for compliance with submitting daily anesthesia resident evaluations 12 months before and 12 months after implementation of a faculty-specific electronic reminder system. Evaluations were entered into a customized, web-based Daily Resident Evaluation database. Data for the reminders were obtained from the Surgical Schedule database. At the end of the study period, data on compliance with our daily resident evaluation system was aggregated by month and compared before versus after system implementation.Main ResultsA total of 1,222 of 3,893 possible evaluations (31.4%) were submitted before the faculty-specific electronic reminder system was in place, with 38 faculty submitting at least one evaluation (93% participation). After the intervention, 1,824 of 4,263 possible evaluations (42.8%) were submitted, with all 41 faculty submitting at least one evaluation (100% participation). The percentage of resident evaluations submitted by the faculty increased from 29.3% to 42.9% (P < 0.0001) after introducing the faculty-specific reminders. Faculty in the lowest quartile of compliance prior to the intervention showed the largest improvement (446% increase).ConclusionsA faculty-specific electronic reminder system improved faculty compliance with submitting resident evaluations. The faculty members with the lowest compliance prior to implementation of this system benefited the most.     

Renal impairment and its impact on clinical outcomes in patients who are critically ill with COVID-19: a multicentre observational study

Renal impairment is common in patients who are critically ill with coronavirus disease-19 (COVID-19). We examined the association between acute and chronic kidney disease with clinical outcomes in 372 patients with coronavirus disease-19 admitted to four regional intensive care units between 10 March 2020 and 31 July 2020. A total of 216 (58%) patients presented with COVID-19 and renal impairment. Acute kidney injury and/or chronic kidney disease was associated with greater in-hospital mortality compared with patients with preserved renal function (107/216 patients (50%) (95%CI 44–57) vs. 32/156 (21%) (95%CI 15–28), respectively; p < 0.001, relative risk 2.4 (95%CI 1.7–3.4)). Mortality was greatest in patients with renal transplants (6/7 patients (86%) (95%CI 47–100)). Mortality rates increased in patients with worsening renal injury according to the Kidney Disease: Improving Global Outcomes classification: stage 0 mortality 33/157 patients (21%) (95%CI 15–28) vs. stages 1–3 mortality 91/186 patients (49%) (95%CI 42–56); p < 0.001, relative risk 2.3 (95%CI 1.7–3.3). Survivors were less likely to require renal replacement therapy compared with non-survivors (57/233 patients (24%) vs. 64/139 patients (46%), respectively; p < 0.001, relative risk 1.9 (95%CI 1.4–2.5)). One-fifth of survivors who required renal replacement therapy acutely in intensive care continued to require renal support following discharge. Our data demonstrate that renal impairment in patients admitted to intensive care with COVID-19 is common and is associated with a high mortality and requirement for on-going renal support after discharge from critical care. Our findings have important implications for future pandemic planning in this patient cohort.     

Programmed intermittent epidural boluses for maintenance of labor analgesia: an impact study

IntroductionThe aim of this impact study was to compare the analgesic efficacy and side effect profile of programmed intermittent epidural boluses (PIEB) + patient-controlled epidural analgesia (PCEA) to continuous epidural infusion (CEI) + PCEA for maintenance labor analgesia after the introduction of PIEB at our institution.MethodsWe conducted a retrospective analysis after replacing the background CEI with PIEB for our labor PCEA. Pre-change pump settings were CEI 12 mL/h with PCEA (12 mL bolus, lockout 15 min); PIEB settings were a 9 mL bolus every 45 min with PCEA (10 mL bolus, lockout 10 min). We compared medical records of all women receiving epidural or combined spinal-epidural labor analgesia for vaginal delivery for two months before PIEB implementation to a two-month period of PIEB utilization following a five-month introductory familiarization period. The primary outcome was the proportion of women requiring rescue clinician boluses.ResultsFewer patients in the PIEB group required rescue clinician boluses compared to the CEI group (12% vs. 19%, P=0.012). Time to first rescue bolus request and total bolus dose were not different. Peak (median [IQR]) pain scores were 2[0–5] with CEI and 0[0–4] with PIEB. There was no difference in instrumental delivery rates.ConclusionsUsing PIEB compared to CEI as the background maintenance epidural analgesia method in conjunction with PCEA reduced the number of women requiring clinician rescue boluses while providing comparable labor analgesia. The findings of this clinical care impact study confirm the results of randomized controlled studies and suggest PIEB may be a preferable technique to CEI for the maintenance of labor analgesia.     

Urinary incontinence--prevalence, impact on daily living and desire for treatment: a population-based study

OBJECTIVE: To investigate the prevalence of urinary incontinence in a representative population in Sweden, and to assess to what extent the condition affects daily life and to what degree those afflicted desire treatment. MATERIAL AND METHODS: In a population-based study, a postal questionnaire comprising 12 questions on urinary incontinence was sent to a representative sample of 15 360 randomly selected residents (aged 18-79 years) of Orebro County, Sweden. This was a supplement to a comprehensive survey of public health and general living conditions. RESULTS: The response rate was 64.5%. The prevalence of urinary incontinence was 19% when defined as "any leakage" and 7% when defined as "at least once a week". Women were more afflicted than men, and the proportion of people with urinary incontinence increased markedly with increasing age. Most considered their problems to be minor, having little impact on daily life, which was reflected by the fact that only 18% of those with urinary incontinence desired treatment. About 17% of those with urinary incontinence reported severe problems that interfered with daily life. Of respondents with severe problems, 42% did not want treatment. CONCLUSION: According to this population-based study, urinary incontinence is not a major problem for most people in the community. Although a considerable proportion of the population report urinary incontinence, the majority experience minor problems and only 18% desire treatment. For a limited group of people, urinary incontinence is a severe problem. It is important that healthcare resources are optimized to identify and meet the needs of those who are most afflicted.     

Orchidopexy for bilateral undescended testes: A multicentre study on its effects on fertility and comparison of two fixation techniques

To evaluate fertility potential after orchidopexy for bilateral undescended testis and compare two surgical fixation techniques for effect on fertility. Men older than 22 years who had either tunica albuginea orchidopexy (TAO) or “no‐touch” technique (NTO) in childhood for bilateral undescended testis (BUDT) were selected. Participants filled out a questionnaire followed by physical examination, had testicular ultrasound, blood sample and semen analysis. Statistical testing was performed using general linear modelling. Sixty‐seven out of 166 individuals responded. Forty‐nine completed the questionnaire, and nine (18.3%) reported having fathered children. Thirty‐six showed up for further examination, 26 had TAO and 10 NTO. Impaired hormonal spermatogenesis regulation (34.6% vs. 20%), higher subfertility rate (46% vs. 20%) and lower means of motile spermatozoa (58.1 × 10⁶ spz vs. 177.9 × 10⁶ spz) were observed in the TAO versus the NTO group; none of these were statistically significant. Four (15.4%) of the TAO and two (20%) of the NTO group have azoospermia. Although the operation technique did not have a significant impact on fertility, unfavourable outcomes were more common after surgery involving the tunica albuginea of the testis. Larger sample sizes are needed to ascertain whether the trends favouring the NTO technique are of any significance.     

Neuropathic vesicourethral dysfunction in children. A trial comparing clean intermittent catheterisation with manual expression combined with drug treatment

Forty-three children with overt neurological disease and neuropathic vesicourethral dysfunction were entered into a trial comparing clean intermittent catheterisation (CIC) with manual expression combined with drug treatment (non-CIC). The 22 children in the CIC group showed a significantly greater improvement in continence than the 21 children in the non-CIC group (P less than 0.001) without a significant increase in the incidence of urinary tract infections. Neither form of treatment is effective in reducing the risk of deterioration of renal function due to the combination of detrusor-sphincter dyssynergia and vesicoureteric reflux. Neither form of treatment improves continence in the presence of gross sphincter weakness or gross impairment of bladder compliance.     

Effect of clean intermittent catheterisation on radiological appearance of the upper urinary tract in children with myelomeningocele

Of the 102 consecutive children with myelomeningocele who were treated by intermittent catheterisation between 1977 and 1985, 89 were investigated with regard to the development of the upper urinary tract. The median follow-up period was 6.7 years. Dilatation and vesicoureteric reflux were assessed by means of repeated urography and voiding cystourethrography. Of the 49 children with normal radiology at the start of catheterisation, all but 2 remained normal. In 27 with isolated dilatation of the upper urinary tract or reflux at the start, 17 subsequently became normal. Dilatation together with reflux was seen in 13 patients at the start; 3 became normal, 4 still had reflux and in 6 patients both dilatation and reflux persisted. Intermittent catheterisation thus had a positive effect on the upper urinary tract in the vast majority of cases. In children with both dilatation and reflux, however, there is a risk of deterioration and they should be followed up closely.     

Growth in children with chronic renal failure on intermittent versus daily calcitriol

Calcitriol (C) treatment strategies for secondary hyperparathyroidism remain controversial regarding efficacy and safety. In children, intermittent C administration has been suspected of impairing body growth. In a prospective, randomized multicenter study, we compared the effect of daily versus twice weekly C on plasma intact parathyroid hormone (iPTH) levels and growth in 24 prepubertal children with chronic renal insufficiency (mean creatinine clearance 20+/-9 ml/min per 1.73 m(2)). After a 3-week washout period, the patients were randomly assigned to 10 ng/kg per day or 35 ng/kg twice a week oral C. The C dose was kept constant for 2 months and could then be adapted to maintain an iPTH target range of 140-280 pg/ml. Median (range) baseline iPTH levels were 567 (114-1209) pg/ml in the daily and 332 (93-614) pg/ml in the intermittent treatment group ( P=NS). After 12 months, iPTH had decreased to 255 (85-710) and 179 (51-443) pg/ml ( P<0.01). The average weekly dose of C was 76+/-34 and 62+/-34 ng/kg ( P=NS). Five episodes of calcium phosphate product>/=70 occurred in the daily group and four in the intermittent group. The change in height standard deviation score during the study period was not affected by either treatment modality (-0.18+/-0.34 vs. -0.05+/-0.52, P=NS). Daily and intermittent C do not differentially affect growth rate and are equally effective in controlling secondary hyperparathyroidism in children with chronic renal failure.     

Resuscitating patients with early severe sepsis: A Canadian multicentre observational study

BACKGROUND: Fluid resuscitation is a key factor in restoring hemodynamic stability and tissue perfusion in patients with severe sepsis. We sought to examine associations of the quantity and type of fluid administered in the first six hours after identification of severe sepsis and hospital mortality, intensive care unit (ICU) mortality, and organ failure. METHODS: A retrospective, multicentre cohort study was undertaken at five Canadian tertiary care ICUs. We identified patients with severe sepsis admitted to the ICU between July 1, 2000, and June 30, 2002, using both administrative and clinical databases. Patients were included if they were hypotensive, had an infectious source, and at least two systemic inflammatory response syndrome criteria. We recorded total quantity and type of fluid administered for the first six hours after severe sepsis was identified. The first episode of hypotension defined the starting point for collection of fluid data. Multivariable regression analyses were performed to examine associations between quantity and type of fluid administered and hospital/ICU mortality, and organ failure. RESULTS: Of 2,026 potentially eligible patient charts identified, 496 patients met eligibility criteria. The mean age and Acute Physiology and Chronic Health Evaluation score (APACHE II) were 61.8 +/- 16.5 yr and 29.0 +/- 8.0, respectively. No associations between quantity or type of fluid administered and hospital mortality or ICU mortality were identified, and there were no statistically significant associations between quantity or type of fluid administered and organ failure. However, more fluid resuscitation was associated with an increased risk of cardiovascular failure [odds ratio (OR) and 95% confidence interval (CI)] for 2-4 L 1.67 (1.03-2.70) and > 4 L 2.34 (1.23-4.44) and a reduced risk of renal failure [OR, 95% CI for 2-4 L 0.48 (0.28-0.83) and > 4 L 0.45 (0.22-0.92)] in the first 24 hr of severe sepsis. Administration of colloid and crystalloid fluid as compared to crystalloid fluid alone was associated with a lower risk of renal failure [OR, 95% CI 0.45 (0.26 to 0.76)]. CONCLUSION: An association between hospital mortality and quantity or type of fluid administered in the first six hours after the diagnosis of severe sepsis was not identifiable. These findings should be considered as hypothesis-generating and warrant confirmation or refutation by randomized controlled trials.     

Histomorphometric evaluation of daily and intermittent oral ibandronate in women with postmenopausal osteoporosis: results from the BONE study

The bisphosphonate ibandronate, administered either daily or intermittently with an extended between-dose interval of >2 months, has been shown to reduce significantly the incidence of vertebral fractures, to increase bone mineral density and to reduce levels of biochemical markers of bone turnover in a phase III randomized study in women with postmenopausal osteoporosis (PMO). Bone histomorphometry was performed on a subgroup of women participating in this study in order to assess bone quality and architecture. The patients were randomized to receive one of the following: placebo, continuous oral daily ibandronate (2.5 mg/day) or intermittent oral ibandronate (20 mg every other day for 12 doses every 3 months). Out of the overall study population of 2,946 patients, 110 were randomly assigned to undergo transiliac bone biopsy at either month 22 or month 34 of treatment. The primary safety endpoint was osteoid thickness in trabecular bone, which was measured to exclude treatment-induced bone mineralization defects. Secondary safety endpoints assessed bone volume, bone turnover and micro-architecture. The primary efficacy endpoint was bone mineralizing surface. In all bone biopsy cores, newly formed trabecular bone retained its structure without any signs of woven bone. Marrow fibrosis and signs of cellular toxicity were not observed. Quantitative assessment demonstrated no impairment in mineralization of bone matrix: osteoid thickness tended to be similar or slightly lower in the ibandronate groups versus the placebo group. All secondary safety variables and the bone efficacy parameter were consistent with the production of normal-quality, newly formed bone and a modest reduction in bone turnover with both ibandronate regimens relative to placebo. Long-term treatment with oral ibandronate, even when administered with an extended between-dose interval of >2 months, produces normal-quality, newly formed bone in women with PMO.     

Psychological impact of the physician-patient relationship on compliance: a case study and clinical strategies

This article presents a case of a heart transplant recipient's noncompliance. A patient's probable medical compliance is among the primary psychosocial criteria in determining his or her eligibility for a heart transplant. The ability to predict and facilitate patient compliance remains a challenge to physicians in all areas of medicine and surgery. The accuracy of the compliance prediction is often contingent upon information generated by patient interviews, other medical personnel, and the patient's family members. All too often, this vital information is based on subjective data, creating difficulty for physicians in appraising patient compliance behavior. Such an amorphous data gathering process may leave physicians at a loss to explain the nature and extent of their patients' behaviors. Research has yet to provide consistent objective measures for compliance prediction. Patient compliance affects all corridors of medical practice and is responsible for an innumerable loss of human life, and financial resources each year.     

A novel protocol of retrograde cerebral perfusion with intermittent pressure augmentation for brain protection

OBJECTIVES: We examined a novel protocol of retrograde cerebral perfusion with intermittent pressure augmentation to improve the clinical usefulness of this procedure, in a canine model, because a high retrograde cerebral perfusion pressure may be required to open cerebral vessels. METHODS: Eighteen dogs (25.2 +/- 4.1 kg) were randomly divided into the following 3 groups: circulatory arrest group (circulatory arrest alone), conventional-retrograde cerebral perfusion group (conventional retrograde cerebral perfusion at 25 mm Hg), and intermittent-retrograde cerebral perfusion group (retrograde cerebral perfusion at 15 mm Hg with intermittent pressure augmentation to 45 mm Hg). The animals were cooled down to 26 degrees C under cardiopulmonary bypass and underwent 60 minutes of circulatory arrest with or without retrograde cerebral perfusion in accordance with the protocol described. They were weaned from cardiopulmonary bypass after rewarming and observed for 12 hours after the procedures. The retinal vessels were observed as a means of noninvasive direct visualization of the cerebral vascular system. The level of Tau proteins in the cerebrospinal fluid was measured as a marker of neuronal damage. RESULTS: While the retinal vessels were fully distended with blood (100%) at a retrograde cerebral perfusion pressure of 45 mm Hg in the intermittent-retrograde cerebral perfusion group, full distension of the retinal vessels was not observed in the conventional-retrograde cerebral perfusion group (67%). The level of Tau proteins, measured 12 hours after the operation, was lower in the intermittent-retrograde cerebral perfusion group (247 +/- 70 pg/mL) than in the circulatory arrest group (1313 +/- 463 pg/mL; P < .05) or the conventional-retrograde cerebral perfusion group (1449 +/- 693 pg/mL; P < .05). Histopathologic examination revealed that the most effective brain protection was obtained in the intermittent-retrograde cerebral perfusion group (P < .05). CONCLUSIONS: Intermittent-retrograde cerebral perfusion effectively opens up cerebral vessels to allow adequate blood supply to the brain, thereby minimizing brain damage. This novel method may protect the cerebral system effectively from ischemia during circulatory arrest.     

Hydrophilic-coated catheters for intermittent catheterisation reduce urethral micro trauma: a prospective, randomised, participant-blinded, crossover study of three different types of catheters

OBJECTIVE: To compare two hydrophilic-coated (SpeediCath and LoFric and one uncoated gel-lubricated catheter (InCare Advance Plus) concerning withdrawal friction force and urethral micro trauma. METHODS: 49 healthy male volunteers participated in this prospective, randomised, blinded, crossover study of three different bladder catheters. The withdrawal friction force was measured, and urine analysis of blood, nitrite and leucocytes, microbiological analysis of urine cultures and subjective evaluation of the catheters were performed. RESULTS: 40 participants completed the study and were included in the analysis. SpeediCath exerted a significantly lower mean withdrawal friction force and work than the gel-lubricated uncoated catheter, whereas LoFric exerted a significantly higher mean friction force than both of the other catheters. The hydrophilic catheters caused less microscopic haematuria and less pain than the gel-lubricated uncoated catheter. Furthermore, 93% of the participants preferred the hydrophilic catheters. CONCLUSION: Hydrophilic-coated catheters perform better than uncoated catheters with regard to haematuria and preference. SpeediCath, but not LoFric, exerts less withdrawal friction force than InCare Advance Plus.     

非那雄胺间歇给药维持良性前列腺增生疗效的临床研究

目的验证非那雄胺间歇给药维持良性前列腺增生（BPH）疗效的可行性并观察间歇给药是否能够减少勃起功能障碍、性欲减退等性功能相关不良反应的发生率。方珐收集泌尿外科门诊符合入组条件的60例患者,将受试者均分为3组,分别予非那雄胺（保列治）5mg1次／d、1次／2d及1次／3d口服,进行为其6个月的随访。以国际前列腺症状评分（IPSS）、生活质量评分（QOL）、前列腺特异性抗原（PSA）、最大尿流率（Qmax）及超声测量作为治疗有效性参数,以勃起功能障碍国际问卷5（IIEF-5）作为治疗前后性功能评价参数。结果1次／3d给药组多数患者于试验开始后2～3周出现明显症状加重,提前终止该组实验。随访1次／d及1次／2d给药组6个月,1次／2d给药组勃起功能障碍发生率略低于1次／d给药组。结论非那雄胺隔日间歇给药可能能够达到维持BPH疗效、减少药物副反应的目的,但这一推断尚需通过更大规模的随机、双盲多中心试验进行证实。     

A novel modality for intraoperative margin assessment and its impact on re-excision rates in breast conserving surgery

Background

A single center retrospective chart review was performed examining the ability of a novel radiofrequency probe (Margin Probe; Dune Medical Devices, Caesarea, Israel) for intraoperative margin assessment to reduce the number of reexcisions in breast-conserving surgery.