Ventilator-associated pneumonia: Incidence,risk factors,outcome, and microbiology

OBJECTIVE: To determine the incidence, risk factors, outcome, and pathogens of ventilator-associated pneumonia (VAP) in a cardiac surgical intensive care unit (ICU). DESIGN: Prospective study. SETTING: Escorts Heart Institute and Research Centre, New Delhi, India. PARTICIPANTS: Nine hundred fifty-two consecutive patients undergoing cardiac operations who received intermittent positive-pressure ventilation (IPPV). INTERVENTIONS: All patients were assigned into VAP (n = 25) and non-VAP (n = 927) groups. MEASUREMENTS AND MAIN RESULTS: Risk factors and other variables were analyzed with univariate and multivariate analysis. Of the 952 patients studied, 25 (2.6%) had VAP. On univariate analysis, significant risk factors were emergency surgery, chronic obstructive pulmonary disease (COPD), reintubation, coma, steroid treatment, intra-aortic balloon counterpulsation (IABC), enteral feedings, tracheostomy, acute physiology, age, and chronic health evaluation (APACHE II) score, prior antibiotics, and IPPV hours. On multivariate analysis, IPPV hours (153.75 +/- 114.44 v 19.65 +/- 7.99; p < 0.001) and steroids (20% v 0%; p < 0.001) were independent predictors of VAP. The most common pathogens isolated were Pseudomonas aeruginosa (22), Escherichia coli (10), Klebsiella pneumoniae (4), Staphylococcus species (4), and Acinetobacter species (2). The mortality rate in VAP was 16% as compared with 0.2% in non-VAP cases (p < 0.001). CONCLUSION: These data suggest that by univariate analysis the risk factors for VAP were emergency surgery, COPD, reintubation, coma, steroid treatment, IABC, enteral feedings, tracheostomy, APACHE II score, prior antibiotics, and IPPV hours. On multivariate analysis, only IPPV hours and steroids were independent predictors of VAP. Pseudomonas aeruginosa is the most common pathogen associated with VAP, and the mortality is increased with VAP.     

Nosocomial infections adversely affect the outcomes of patients with serious intraabdominal infections

BACKGROUND: Patients with serious intraabdominal infections (IAI) who subsequently acquire nosocomial infections (NI) have been shown to have adverse outcomes. We evaluated factors that put patients at risk for developing NI and examined the effect of the NI on outcomes. METHODS: This study was a retrospective review of NI among 168 patients diagnosed with IAI over a seven-year period. RESULTS: Sixty-six patients (39.3%) developed 98 NI (23 urinary tract, 20 surgical site, 19 pneumonia, 14 bloodstream, 12 recurrent peritonitis, seven intravascular catheter-related, and three enteric). There were 35 males and 31 females. Patients with NI were older (56.0 +/- 18.3 vs. 47.0 +/- 15.6 years, p = 0.001), had a higher admission APACHE II score (10.7 +/- 6.1 vs. 7.5 +/- 5.1 points, p = 0.001), and more often had concomitant medical diagnoses (27.3% vs. 12.7%, OR = 2.57, 95% CI: 1.159-5.69, p = 0.018) than those who did not develop infection. Antimicrobial resistance among the IAI was higher in the NI group (19.7 vs. 5.9%, OR = 3.93, 95% CI: 1.41-10.93, p = 0.006). Patients who developed NI had an increased mortality rate (27.0% vs. 4.0%, OR = 8.87, 95% CI: 2.82-27.86, p < or = 0.0001), longer hospital stay (24.7 +/- 19.5 vs. 11.7 +/- 8.1 days, p < or = 0.0001), required more days of intravenous antibiotics (11.5 +/- 8.0 vs. 7.6 +/- 4.4 days, p < or = 0.0001), and were more likely to be admitted to an intensive care unit (54.5% vs. 25.5%, OR = 3.51, 95% CI: 1.82-6.77, p < or = 0.0001). Multivariate analysis demonstrated that antimicrobial resistance and an APACHE II score of > or = 10 independently predicted the development of a nosocomial infection. Age >/= 50 years, APACHE II score > or = 10, or the presence of a NI independently predicted death. CONCLUSIONS: The development of NI following treatment of an IAI significantly affects mortality, hospital length of stay, and treatment. Early recognition and treatment of these infections, combined with strategies to prevent NI, may be important to improve outcomes in this patient population.     

Vascular-access infections in hospitalized patients

Vascular catheters are a common source of nosocomial infections, although many of these infections are potentially preventable. A long duration of catheterization, multiple catheter manipulations, the inexperience of some inserters, use of transparent plastic dressings, violations of aseptic technique, the use of multilumen catheters, and inadequate sterilization of reusable pressure transducers all increase the risk of these infections. The only interventions that have been proved to reduce the risk are standardized insertion and maintenance technique by an intravenous-therapy team, preinsertion skin preparation with chlorhexidine gluconate, and the use of topical antibiotics at the insertion site. The goal of the physician should be to prevent catheter infection, because the treatment of established infection can be difficult and costly. Treatment must be individualized for each patient on the basis of the clinical presentation and the causative organism.     

What really affects the incidence of central venous catheter-related infections for short-term catheterization?

Central venous catheterization is one of the important sepsis reasons in surgical patients. In this randomized controlled study, the effect of the frequency and type of catheter site care, as well as age, coexisting malignancy or diabetes mellitus, total parenteral nutrition administration and antibiotics use, on central venous catheter infection was investigated. Seventy-two single-lumen polyurethane catheters were included. In group I (n: 33), a transparent occlusive dressing was applied to the insertion site and not removed for 7 days unless there were signs of local infection. In group II (n: 39), daily site care was done with povidone-iodine 10% solution and a new sterile gauze was applied. Chi-square, linear correlation and multiple regression tests were used for statistical analysis. Mean duration of catheters was 8 +/- 4 days. There was no catheter-related sepsis. Ten (13.9%) patients had positive catheter tip cultures of whom three had site infection as well. The incidence of site and tip infections were not significantly different in group I and II (p > 0.05). Site infection and age younger than 60 years significantly increased the rate of tip infection (p: 0.004 and p: 0.02 respectively). Total parenteral nutrition administration was associated with higher rate of tip infection (p: 0.06). Coexisting malignancy or diabetes mellitus, duration of catheter and antibiotics use did not have any significant effect on the rate of central venous catheter infections (p > 0.05). In conclusion, we observed that the frequency of insertion site care and the type of dressing applied to the site had no significant effect on the rate of CVC infection. Insertion site infection was the most significant factor increasing the incidence of catheter tip infection. The use of the CVC for total parenteral nutrition facilitated tip infection as well.     

The role of intra-aortic counterpulsation in high-risk OPCAB surgery: a prospective randomized study

BACKGROUND: High-risk patients would benefit the most of OPCAB revascularization. This prospective and randomized study evaluates the efficacy and safety of pre- and perioperative IABC in high-risk OPCAB. MATERIAL: Group A-IABC started prior to induction of anesthesia (n = 15); group B-no preoperative IABC (n = 15). Adult high-risk coronary patients to undergo OPCAB. High risk = (minimum 2) EF < 0.30, left main stenosis, unstable angina, redo. Bailout if hemodynamic instability CPB or IABC in group B. Study endpoints (a) cardiac protection (troponin 1, cardiac index (CI), ECG), (b) inflammatory response (lactate, IL-6), (c) clinical outcome (mortality, morbidity). Emergency operations 33%, re-operation 13%, unstable angina 100%, left main 60% and EF 0.29, without group differences. RESULTS: No bailout group A, 10 in group B, p < 0.0001. Postoperative IABC six (group A) and seven patients (group B), during 6.8 +/- 5.1 hours (group A) versus 41.2 +/- 25.5 hours (group B), p = 0.0110. Myocardial protection without group differences, but CI significantly better in group A. Inflammatory response significantly less in group A. CLINICAL OUTCOMES: one death, one MI and two renal failure in group B, none in group A. Intensive care unit (ICU) stay 27 +/- 3 hours (group A) versus 65 +/- 28 hours (group B), p = 0.0017. LOS 8 +/- 2 days (group A) versus 15 +/- 10 (group B), p = 0.0351. No IABC related complications. CONCLUSIONS: Pre- and perioperative IABC therapy offers efficient hemodynamic support during high-risk OPCAB surgery, lowers the risk of hemodynamic instability, is safe and shortens both ICU and hospital length of stay significantly, and is a cost-effective therapy.     

Systemic coagulation changes caused by pulmonary artery catheters: laboratory findings and clinical correlation

BACKGROUND: A higher rate of pulmonary embolism has been associated with pulmonary artery (PA) catheters; however, no mechanism has been described. Conventional tests of coagulation reveal no changes related to PA catheterization. The purpose of this study was to determine whether PA catheterization resulted in a hypercoagulable state detectable by thrombelastography (TEG). METHODS: Animal: Healthy, anesthetized, swine (n = 19) underwent PA catheterization. Samples were drawn from 7F femoral arterial catheters before and two hours after PA catheterization, at 5 mL/min, and analyzed (native whole blood, n = 15, kaolin activated blood, n = 4) by TEG (Hemoscope, Niles, IL) at precisely two minutes. Human: An IRB-approved prospective, observational trial was conducted in critically ill patients (n = 19). Samples were drawn from 22-gauge radial artery catheters, before and three hours after PA catheterization. Kaolin-activated TEG samples were analyzed at precisely five minutes. Data are mean +/- SE; Groups were compared with analysis of variance and significance was assessed at the 95% confidence interval. RESULTS: In both animals and patients, PA catheterization truncated R times (time to initial fibrin formation). In swine, the R times were 17.6 +/- 1.3 minutes (native) and 3.8 +/- 0.4 (kaolin) before PA catheterization, and decreased to 6.3 +/- 1.0 minutes (p = 0.002) and 1.9 +/- 0.5 minutes (p = 0.010) afterward. There were no changes in pH or temperature during the experiment. In patients, 4 of 19 were excluded for protocol violations. The R time was 6.3 +/- 1.0 minutes (kaolin) before and 3.0 +/- 0.3 minutes after catheterization (p = 0.003). No changes were observed in conventional coagulation parameters, temperature or pH. CONCLUSION: In healthy swine, and critically ill patients, PA catheters may enhance thrombin formation and fibrin polymerization, indicating a systemic hypercoagulable state. This may explain why PA catheters are associated with an increased risk of pulmonary emboli.     

Bacteremia associated with central venous catheter infection is not an independent predictor of outcomes

Background: Infection is the leading complication of central venous catheters. In the setting of suspected line infection, the CDC recognizes only catheter-related bloodstream infection but not catheter infection without bacteremia, which is designated “colonization.” To evaluate the hypothesis that catheter-related bloodstream infection has worse outcomes than catheter infection without bacteremia, we compared demographics, clinical data, and outcomes.

Study Design: Analysis of catheter infections was performed on data collected prospectively for all episodes of infection occurring from December 1996 to September 1999 on the surgical services at a university hospital. Catheter tips were cultured only when infection was suspected. Catheter infection without bacteremia was defined as systemic evidence of infection, the presence of at least 15 colony-forming units on the catheter tip by a semiquantitative technique, and absence of bloodstream infection with the same organism as the catheter. Catheter-related bloodstream infection required the presence of bacteremia with the same organism as the catheter tip.

Results: The 59 patients with catheter-related bloodstream infection had more coexistent infections than the 91 patients with catheter infection without bacteremia (2.9 ± 0.1 versus 1.7 ± 0.1; p = 0.0001), most commonly pneumonia (37.3% versus 16.5%, p = 0.004) and urinary tract infections (28.8% versus 8.8%, p = 0.001). Catheter-related bloodstream infection was associated with an increased proportion of gram-negative organisms compared with catheter infections without bacteremia (29.5% versus 16.9%, p = 0.04) and a trend toward fewer gram-positive organisms (61.5% versus 73.7%, p = 0.07). There were no differences in APACHE II score, WBC, length of hospital stay, time from admission to fever, time from fever to treatment, normalization of WBC, days of antibiotics, defervescence, gender, presence of comorbidities, occurrence of colonization while in an ICU, or mortality rate (18.6% with bacteremia, 24.2% without; p = 0.42).

Conclusions: The presence of bloodstream infection in addition to catheter infection does not appear to alter outcomes. The definition of catheter infection perhaps should be extended to include catheter infections without bloodstream infection in the presence of systemic illness without another source.     

Painless intravenous catheterization by intradermal jet injection of lidocaine: a randomized trial.

STUDY OBJECTIVE: To compare efficacy and cost of lidocaine cutaneous anesthesia by two jet injectors to routine needle infiltration for pain relief of intravenous (i.v.) catheterization, hypothesizing that jet injection of lidocaine is less painful than its needle infiltration. DESIGN: Randomized, prospective, controlled trial. SETTING: University hospital outpatient surgical unit. PARTICIPANTS: 75 surgical patients ASA I and II. INTERVENTIONS: Three groups of 25 patients each were given intradermal lidocaine anesthesia via conventional 25-gauge needle/syringe; by MedEJet or Biojector jet injector prior to IV catheterization with an 18-gauge Jelco catheter. MEASUREMENTS AND MAIN RESULTS: Visual analogue pain scores (VAS) (0 = no pain, 10 = intolerable pain) and subjective pain intensity scores (PIS) (0 = not painful, 4 = intolerable pain) at lidocaine application and at i.v. catheterization, were recorded. Cost assessment of each method was made. At local anesthetic application, no pain by proportion of VAS = 0 with MedEJet: 25/25 (confidence interval [CI]: 0.868, 0.999) and Biojector: 24/25 (CI 0.804, 0.991) was noted, but-22 of 25 patients experienced pain with needle administration: (with VAS = 0; 3/25 [CI: 0.044, 0.302]) (posterior probability [PP] > 0.999). The corresponding VAS scores (means +/- SD) were 0.00 +/- 0.00, 0.04 +/- 0.20, and 2.4 +/- 2.23 (p < 0.001). No pain by proportion of PIS = 0 with MedEJet: 25/25 (CI: 0.868, 0.999 and Biojector: 23/25 (0.749, 0.976) was noted, but pain in 20/25 was felt with the needle: 5/25 (CI: 0.090, 0.394) (PP > 0.999). The corresponding PIS scores were 0.00 +/- 0.00, 0.16 +/- 0.55, and 1.24 +/- 1.00 (p < 0.001). At i.v. catheterization, no pain by proportion of VAS = 0 with MedEJet: 22/25 (CI: 0.698, 0.956) or Biojector: 21/25 (CI: 0.651, 0.934) was noted; but pain in 19/25 with needle administration was experienced: 6/25 (CI: 0.116, 0.436) (PP > 0.999). The corresponding scores were 0.12 +/- 0.33, 0.44 +/- 0.20, and 1.64 +/- 1.50 (p < 0.001). No pain by proportion of PIS = 0 with MedEJet: 24/25 (CI: 0.804, 0.991) or Biojector: 24/25 (CI: 0.804, 0.991) was noted, but pain was apparent in 12/25 with needle administration: 13/25 (CI: 0.334, 0.701) (PP > 0.999). The corresponding scores were 0.00 +/- 0.00, 0.00 +/- 0.00, and 0.76 +/- 0.88 (p < 0.001). Cost per application: MedEJet = $0.13; needle/syringe = $0.50; Biojector = $0.94. CONCLUSIONS: Almost completely painless i.v. catheterization was carried out by jet injection of lidocaine, but needle infiltration produced discomfort or pain and did not significantly reduce discomfort or pain at the i.v. needle insertion.     

Influences on renal function in chronic spinal cord injured patients

PURPOSE: The optimal method of bladder management in the spinal cord injured population remains controversial. We determined the significance of bladder management and other factors on renal function in this population. MATERIALS AND METHODS: We retrospectively reviewed the medical records and upper tract imaging studies of 308 patients with a mean followup of 18.7 years since injury. Renal function was assessed by serum creatinine, creatinine clearance and proteinuria measurement, and by upper tract abnormalities on renal ultrasound and nuclear medicine renal scan. Independent variables evaluated for an influence on renal function included patient age, interval since injury, injury level and completeness, vesicoureteral reflux, history of diabetes mellitus and bladder management method. RESULTS: Mean serum creatinine plus or minus standard deviation in patients on chronic Foley catheterization, clean intermittent catheterization and spontaneous voiding was 1.08 +/- 0.99, 0.84 +/- 0.23 and 0.97 +/- 0.45 mg./dl. (analysis of variance p = 0.05, Student's t test p = 0.10), and mean creatinine clearance was 91.1 +/- 46.5, 113.4 +/- 39.8 and 115 +/- 49 ml. per minute, respectively (analysis of variance and Student's t test p <0.01), respectively. Proteinuria was present in 19 patients (6.2%) in the Foley catheterization, 3 (1%) in the clean intermittent catheterization and 4 (1.3%) in the spontaneous voiding group (chi-square test p <0.01), while there were upper tract abnormalities in 56 (18.2%), 20 (6.5%) and 24 (7.8%) patients, respectively (chi-square test p <0.01). Multiple regression analyses revealed no significant predictors of serum creatinine, although older patient age and Foley catheterization significantly predicted low creatinine clearance. Additional logistic regression analyses showed that Foley catheterization was associated with proteinuria and vesicoureteral reflux was associated with upper tract abnormalities. CONCLUSIONS: While renal function may be preserved by all forms of bladder management, chronic indwelling catheters may contribute to renal deterioration.     

A prospective, randomized, controlled trial of primary wound closure after lateral internal sphincterotomy

BACKGROUND: Much of the lateral internal sphincterotomy (LIS) complications is related to LIS incision. In this study, incisions sutured primarily or left to secondary healing after open LIS procedure are compared regarding the wound healing and complications associated with wounds. METHODS: Planning a prospective, randomized clinical study, 39 patients were separated into two groups. Open LIS was performed on both of the groups. While the incisions of the patients in group 1 (n = 22) were closed with two interrupted sutures using 3-0 chromic catgut, the incisions of the patients in group 2 (n = 17) were left open. The patients were followed up for 90 days postoperatively. RESULTS: Hematoma in 1 (4.5%), ecchymosis in 7 (31.8%), and wound infection in 1 (4.5%) developed in patients of group 1. In this group no significant external bleeding was seen. Wound healing duration was 15.05 +/- 5.60 days. In group 2 no hematoma developed (P = 0.98), but 2 (11.7%) ecchymoses (P = 0.25), 4 (23.5%), wound infections (P = 0.14), and 3 (17.6%) postoperative significant external bleedings (P = 0.07) were seen. Wound healing duration was 33.94 +/- 6.67 days (P <0.001). CONCLUSIONS: To achieve early wound healing, primary closure of open LIS incision is useful, but this technique has no significant effect on wound-related complications in comparison with secondary healing.     

Central venous catheter infections at a county hospital in Sweden: a prospective analysis of colonization, incidence of infection and risk factors

BACKGROUND: Catheter-related infection (CRI) is one of the most serious complications of the use of central venous catheters (CVCs), with an incidence of 2-30/1000 days in different studies. No major prospective study has evaluated the rate of CRI in Scandinavia. Since 1999, we have had a thorough programme for the insertion and care of all CVCs used at our hospital and its outpatient clinics. The purpose of this survey was to study the incidence of catheter tip colonization and CRI and their risk factors, and to compare these data with previous non-Scandinavian studies. METHODS: We studied prospectively 605 CVCs in 456 patients in relation to insertion data, patient and catheter characteristics, catheterization time and microbiological cultures. Risk factors were analysed by multivariate analysis. RESULTS: Four hundred and ninety-five (82%) of all CVCs were assessed completely. The total catheterization time was 9010 days. The incidence of positive tip culture was 7.66/1000 days, and the predominant microorganism was coagulase-negative staphylococci. The incidence of CRI was 1.55/1000 days, and the only significant risk factor was the duration of catheterization with a relative risk of 1.009 per day [95% confidence interval (CI), 1.003-1.015]. Of the 14 cases with CRI, six were associated with candida species, and five of these were diagnosed in the intensive care unit. CONCLUSION: In comparison with non-Scandinavian studies, our practice of strict basic hygiene routines for CVC insertion and care is associated with a low incidence of CRI. However, there was a high proportion of candida species amongst these infections. The only risk factor for CRI was the duration of catheterization.     

Efficacy and safety of oxybutynin in children with detrusor hyperreflexia secondary to neurogenic bladder dysfunction

PURPOSE: We evaluated the efficacy and safety of oxybutynin in children with detrusor hyperreflexia due to neurological conditions. MATERIALS AND METHODS: Study 1--A prospective, open label trial of 3 formulations of oxybutynin (tablets, syrup and extended release tablets) was conducted for 24 weeks in children 6 to 15 years old with detrusor hyperreflexia who used oxybutynin and clean intermittent catheterization. The effect of treatment on average urine volume per catheterization and on secondary urodynamic outcomes was evaluated. Study 2--The efficacy and safety of oxybutynin syrup were evaluated urodynamically in an open label study of children 1 to 5 years old with detrusor hyperreflexia who used oxybutynin and clean intermittent catheterization. RESULTS: Study 1--Mean urine volume per catheterization (+/- SEM) increased by 25.5 +/- 5.9 ml (p <0.001). Maximal cystometric capacity increased by 75.4 +/- 9.8 ml (p <0.001). Mean detrusor and intravesical pressures were significantly decreased by -9.2 +/- 2.3 (p < or =0.001) and -7.5 +/- 2.5 cm H2O (p <0.004), respectively, at week 24. Of 61 children with uninhibited detrusor contractions 15 cm H2O or greater at baseline 34 did not have them at week 24 (p <0.001). Improvements in bladder function were consistent across all oxybutynin formulations. Study 2--Mean maximal cystometric capacity increased significantly by 71.5 +/- 21.99 ml (p = 0.005). At study end only 12.5% of patients had uninhibited detrusor contractions 15 cm H2O or greater compared with 68.8% at baseline (p = 0.004). Oxybutynin was well tolerated in both studies. There were no serious treatment related adverse events. CONCLUSIONS: All 3 formulations of oxybutynin are safe and effective in children with neurogenic bladder dysfunction.     

Intra-aortic balloon counterpulsation: Outcome in cardiac surgical patients

OBJECTIVE: To identify the major determinants of survival and nonsurvival for patients in need of intra-aortic balloon pump (IABP) support after cardiac surgery and to define the role of ventilator-associated pneumonia. DESIGN: Retrospective study. SETTING: University and general hospital. PARTICIPANTS: A total of 105 consecutive patients undergoing cardiac surgery requiring IABP support and prolonged mechanical ventilation for >24 hours. INTERVENTION: All patients were assigned into 1 of 2 groups: survival (n = 69) and nonsurvival (n = 36). MEASUREMENTS AND MAIN RESULTS: Differences between the survival and nonsurvival groups were tested with the Student's t-test, chi-square test, and frequency analysis. The overall survival rate was 65.7%. Nonsurvivors (34.3%) had higher rates of acute myocardial infarction (27.7% v 4.3%; p < 0.002), Canadian Cardiovascular Society functional class III and IV (44.4% and 13.8%; p < 0.001), and depressed left ventricular ejection fraction (31.3 +/- 6.4% v 42.4 +/- 7.2%; p < 0.001). The nonsurvival group had longer duration of cardiopulmonary bypass (165 +/- 74.3 minutes v 135 +/- 36 minutes; p < 0.006) and aortic occlusion (81.8 +/- 9 minutes v 68.6 +/- 25.7 minutes; p < 0.004). In the nonsurvival group, 21 patients were not weaned from the IABP, and 15 patients were weaned from the IABP but died from renal failure (26.6%), multiorgan failure (13.3%), infection, and respiratory failure (66.6%). In the nonsurvival group, mechanical ventilation time was longer in patients weaned from the IABP. CONCLUSION: These data suggest that for patients not weaned from the IABP, the major determinants of death are low cardiac output (33.3%) and multiorgan failure (47.6%). Patients with a left ventricular ejection fraction of <30% have a poorer outcome. In patients weaned from the IABP, ventilator-associated pneumonia (66.6%) was the major cause of death.     

Catheterization of the radial or brachial artery in neonates and infants

Background : In neonates and small children, percutaneous insertion of arterial catheters may be very difficult because of the small diameter of the arteries. Multiple attempts at cannulation are common and may be a predictor of serious adverse events following arterial cannulation. As an endartery, the brachial artery is usually not recommended for cannulation. However, limited data exist about brachial artery catheterization in neonates and young children. In this retrospective study, we report our experience with arterial indwelling catheters placed in neonates and small children prior to surgery for congenital heart defects. Methods : We reviewed 1473 patient medical files containing information about 1574 arterial lines for perioperative and intensive care monitoring. Patient data (age and weight), cannulation characteristics (site, type, percutaneous or cut down insertion), duration of catheterization and complications were documented using the anesthesia and/or intensive care unit files. Patients were divided into three groups according to body weight. Group I: patients with a bodyweight up to 5 kg (n = 561), group II: bodyweight 5–10 kg (n = 615), and group III: bodyweight 10–20 kg (n = 297). Results : The vast majority of our patients had radial or brachial artery catheterization. In group 1, we placed 200 brachial artery lines. Radial artery insertion was more successful with increasing body weight. Two ‘cut downs’ were necessary to place the arterial cannula (0.3%). The mean duration of the arterial cannula in place was 5.8 + 4.3 days in group I, which was significantly longer than in group III (2.9 + 2.2 days). Multiple attempts at catheter insertion were required for 200 patients in group I (P < 0.05 compared with groups II and III). The number of guide wires used was similar in all study groups. Generally, we preferred 24 and 22 G catheters for cannulation. Serious complications such as permanent ischemic damage were not observed. Temporary occlusion of an artery occurred in five of 1473 patients. The rate of local infection was 0.5% in group I, 0.7% in group II and 2.3% in group III. Local hematoma were observed more frequently, but with no relevant consequences. Most of our patients were cannulated on the right side. In group I, 112 brachial artery catheters were placed. The greater the weight, the more radial catheters were used compared with a brachial approach. The mean functional time of the catheters (5.8 ± 4.3 days in group I) was significant shorter compared with patients from group III (2.9 ± 2.2 days). In 33.3% (n = 200) multiple punctures were needed to place a catheter in group I (P < 0.05 compared with the other groups) whereas the use of a guide wire was evenly distributed throughout the study groups. Small catheters (24 and 22 G) were preferred for most patients. In total only eight 20 G sized catheters were used in the children of group III. Conclusions : Even considering the nature of a retrospective study design, we conclude that the brachial artery could be considered for cannulation in neonates and small children.     

Persistent Sciatic Artery Aneurysm: a Case Report

Central venous catheterization is one of the important sepsis reasons in surgical patients. In this randomized controlled study, the effect of the frequency and type of catheter site care, as well as age, coexisting malignancy or diabetes mellitus, total parenteral nutrition administration and antibiotics use, on central venous catheter infection was investigated.

Seventy-two single-lumen polyurethane catheters were included. In group I (n: 33), a transparent occlusive dressing was applied to the insertion site and not removed for 7 days unless there were signs of local infection. In group II (n: 39), daily site care was done with povidone-iodine 10% solution and a new sterile gauze was applied. Chi-square, linear correlation and multiple regression tests were used for statistical analysis.

Mean duration of catheters was 8 ±4 days. There was no catheter-related sepsis. Ten (13.9%) patients had positive catheter tip cultures of whom three had site infection as well. The incidence of site and tip infections were not significantly different in group I and II (p > 0.05). Site infection and age younger than 60 years significantly increased the rate of tip infection (p: 0.004 and p: 0.02 respectively). Total parenteral nutrition administration was associated with higher rate of tip infection (p: 0.06). Coexisting malignancy or diabetes mellitus, duration of catheter and antibiotics use did not have any significant effect on the rate of central venous catheter infections (p > 0.05).

In conclusion, we observed that the frequency of insertion site care and the type of dressing applied to the site had no significant effect on the rate of CVC infection. Insertion site infection was the most significant factor increasing the incidence of catheter tip infection. The use of the CVC for total parenteral nutrition facilitated tip infection as well.     

The effect of suprapubic catheterization versus transurethral catheterization after abdominal surgery on urinary tract infection: a randomized controlled trial

BACKGROUND/AIM: Transurethral catheterization is generally associated with a higher incidence of urinary tract infections than suprapubic catheterization; however, suprapubic catheterization is associated with other disadvantages such as higher costs and a more difficult technique, and at the moment there is no consensus about the use of both catheter systems. Therefore, a prospective randomized study was performed to investigate the effects of suprapubic catheterization and transurethral catheterization in patients undergoing surgery on the incidence of urinary tract infections and patient satisfaction. METHODS: Patients who underwent an elective laparotomy were randomized and received a suprapubic or transurethral catheter. The primary end point was urinary tract infection. Other parameters of urinary tract infection, as well as duration of catheterization, hospital stay, and number of recatheterizations and of relaparotomies were monitored. Treatment 'per protocol' was also analyzed after exclusion of patients receiving another catheter than randomized for. Patients were asked for their satisfaction with the catheters and complaints during and after catheterization. RESULTS: 165 patients were eligible, of whom 19 patients had to be excluded. 75 patients were allocated to receive the suprapubic catheter and 71 the transurethral catheter. There was no difference in the incidence of a urinary tract infection between the suprapubic group (n = 9/75; 12%) and the transurethral group (n = 8/71; 11%). Most patients (6/9) who developed a urinary tract infection in the suprapubic group, however, underwent recatheterization because of postoperative complications/sepsis and relaparotomy. The incidence of urinary tract infections in patients who received a suprapubic catheter and not a transurethral catheter was 3/59 (5%). The patients did not differ with respect to satisfaction and complaints. Being a men, recatheterization and duration of catheterization are risk factors. CONCLUSIONS: The incidence of a urinary tract infection between a suprapubic catheter and a transurethral catheter in patients undergoing major surgery was not different. A potential advantage of the suprapubic catheter (reduction of urinary tract infections) is probably partly negated, because transurethral catheters were used if recatheterization was indicated during the postoperative stay or due to complications.     

Factors that exaggerate the deleterious effects of pulmonary insufficiency on the right ventricle after tetralogy repair. Surgical implications

Postoperative cardiac catheterization data of 74 patients with pulmonary insufficiency after tetralogy repair were analyzed. Two groups were identified: Group A, 26 patients with normal right ventricular function (ejection fraction 95% +/- 5.5%, end-systolic volume 110% +/- 17% of predicted normal) and Group B, 48 patients with right ventricular dysfunction (ejection fraction 80% +/- 18% [p less than 0.001], and end-systolic volume 218% +/- 75% of predicted normal [p less than 0.001]). There was no significant difference between the two groups with respect to frequency of previous palliative procedures, age at operative repair, operative techniques, methods of myocardial protection, and follow-up period. Right ventricular dysfunction in Group B was associated with significant distal pulmonary stenosis (right ventricle-pulmonary artery pressure gradient 28 +/- 13 torr in Group A versus 55 +/- 20 torr in Group B, p less than 0.001), moderate pulmonary regurgitation (regurgitant fraction 18% +/- 11% in Group A versus 32% +/- 10% in Group B, p less than 0.001), and large transannular outflow patch (ratio of patch diameter to descending aorta diameter 1.31 +/- 0.16 in Group A versus 2.50 +/- 0.28 in Group B, p less than 0.001). Pulmonary valve insertion was performed in 42 patients in Group B. Eighteen had subsequent cardiac catheterization. Right ventricular function recovered completely (end-systolic volume 122% +/- 24%, and ejection fraction 92% +/- 7% of predicted) in five of six patients (83%) who had valve insertion within the first 2 years after tetralogy repair. In contrast, right ventricular function remained abnormal in all 12 patients who had valve insertion later than 2 years after tetralogy repair (p less than 0.05). Patients with residual pulmonary stenosis and/or a large transannular outflow patch are at risk for the development of right ventricular dysfunction from pulmonary insufficiency after tetralogy repair. Early correction of these residual lesions and control of pulmonary insufficiency may prevent long-term deterioration in right ventricular function.     

Readmission to surgical intensive care increases severity-adjusted patient mortality

BACKGROUND: This study aims to determine whether severity-adjusted outcomes including mortality are adversely impacted by readmission to a surgical intensive care unit (SICU) during the same hospital stay. METHODS: The study included all patients admitted to the 20-bed tertiary care SICU in an urban teaching Level I trauma center and multiorgan transplant center from January 1, 1996 to December 31, 2001. This was a prospective observational study with secondary data analysis. Acute Physiology and Chronic Health Evaluation (APACHE II) and Simplified Acute Physiology (SAPS) severity scores were calculated by a clinical information system. Outcomes were extracted from a computerized data warehouse. RESULTS: In-hospital mortality and SICU length of stay (LOS) were measured for patients admitted and readmitted to the SICU. Of 10,840 patients admitted to the SICU, 296 (2.73%) required readmission to the SICU during the same hospital stay. The length of the original SICU stay was 4.9 +/- 6.7 days for readmitted patients compared with 3.2 +/- 6.0 days for nonreadmitted patients (p < 0.001). Readmitted patients had a higher mean APACHE II score on the day of original SICU discharge compared with nonreadmitted patients, 15.7 +/- 6.7 versus 13.8 +/- 7.1 (p < 0.001). The average APACHE II score increased from 15.7 +/- 6.7 to 18.1 +/- 8.6 between the day of SICU discharge and readmission (p < 0.001) and SAPS increased from 12.2 +/- 4.8 to 13.5 +/- 5.4 (p < 0.001). The distributions of severity-adjusted hospital mortality for both APACHE II and SAPS revealed that readmission to the SICU significantly increased mortality independent of the admission severity score. CONCLUSIONS: Readmission to the SICU significantly increases the risk of death beyond that predicted by the APACHE II or SAPS scores alone. Higher APACHE II and SAPS scores upon discharge from the SICU and longer SICU LOS are associated with an increased incidence of readmission to the SICU on the same hospital stay. These results may be used to optimize the timing of SICU discharge and reduce the chance of readmission to intensive care.     

Infectious complications related to non-tunneled central venous catheters in immunocompromised patients: prospective study about 210 cases

OBJECTIVE: To evaluate infectious complications related to non-tunneled central venous catheter in immunocompromised patients, in a bone marrow unit. METHODS: From July to April 2002, we inserted 210 non-tunneled central venous catheters in 139 immunocompromised patients (52 F/87 M). The mean age was 26 years (3-56 years). Our study included 33 children aged from 3 to 15 years, on whom 46 catheters were placed. The catheters were placed for the following indications: 145 catheters were used in subjects who received a bone marrow transplantation, 58 catheters were placed in subjects who received chemotherapy for acute leukemia and seven catheters were used in patients who received immunosuppressive therapy. RESULTS: The mean duration of catheterization was 33 days (7-114 days). There were 3.1 catheter-related infections per 1000 catheter-days. Coagulase-negative Staphylococci were implicated in 64% of cases. We observed two pneumothorax (0.9%), one arterial puncture (0.4%) and two catheter-related thrombosis (0.9%). CONCLUSION: Non-tunneled catheters in immunocompromised patients (adults and children) is a safe technique, and is an alternative to the Hickman catheters which are most widely used today in patients undergoing bone marrow transplantation.     

Bladder Management in Patients With Pediatric Onset Neurogenic Bladders

Abstract

Our objective was to determine which clean intermittent catheterization (CIC) methods and supplies were used by patients with pediatric onset neurogenic bladders and to relate methodology and materials to reported urinary tract infections. Data were collected via questionnaires distributed by mail and at clinic visits at our university tertiary care outpatient pediatric rehabilitation clinic. Questionnaires were given to 165 patients. Fifty-nine percent were returned (68 patients with myelomeningocele, 27 with pediatric onset spinal cord injury (SCI) and two with other diagnoses). Mean age was 12 years (range 1-27). Fifty-four percent of patients participated in their own CIC. Only two percent used sterile catheterization technique, whereas 98 percent used CIC. A sterile catheter was employed with clean technique by 22 percent. Catheters were reused by 76 percent. Subjects used a wide ranging number of catheters per month, with a median of 5.3. There was no correlation between the number of urinary tract infections (UTIs) per year and the type of catheter used or the use of prophylactic antibiotics. Compared with patients with myelomeningocele, subjects with SCI were significantly more likely to use sterile catheters (p=0.04), >10 catheters per month (p=0.01) and gloves (p<0.001). Subjects who used gloves or more catheters were more likely to experience UTI. These data suggest that clean reused supplies are not related to an increased likelihood of UTI and should be considered a way to lower costs in these populations. (J Spinal Cord Med 1997;20:410-415)