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Objective To compare routine replacement of intravenous peripheral catheters with replacement only when clinically indicated.

Design Randomised controlled trial.

Setting Tertiary hospital in Australia.

Participants 755 medical and surgical patients: 379 allocated to catheter replacement only when clinically indicated and 376 allocated to routine care of catheter (control group).

Main outcome measure A composite measure of catheter failure resulting from phlebitis or infiltration.

Results Catheters were removed because of phlebitis or infiltration from 123 of 376 (33%) patients in the control group compared with 143 of 379 (38%) patients in the intervention group; the difference was not significant (relative risk 1.15, 95% confidence interval 0.95 to 1.40). When the analysis was based on failure per 1000 device days (number of failures divided by number of days catheterised, divided by 1000), no difference could be detected between the groups (relative risk 0.98, 0.78 to 1.24). Infusion related costs were higher in the control group (mean $A41.02; £19.71; €24.80; $38.55) than intervention group ($A36.40). The rate of phlebitis in both groups was low (4% in intervention group, 3% in control group).

Conclusion Replacing peripheral intravenous catheters when clinically indicated has no effect on the incidence of failure, based on a composite measure of phlebitis or infiltration. Larger trials are needed to test this finding using phlebitis alone as a more clinically meaningful outcome.

Registration number Australian New Zealand Clinical Trials Registry ACTRN12605000147684.

Catheter insertion for intravenous hyperalimentation is a commonly and widely used clinical technique. When compared with the incidence of complications associated with insertions into the internal jugular vein or the subclavian vein, complications associated with insertions into the femoral vein are less frequent. In this paper, we describe a very rare complication of femoral vein catheter insertion—namely, catheter displacement into the inferior epigastric vein.

Aim

To evaluate the histomorphological features of veins in normal and transplanted kidneys.

Methods

Between 1992 and 1997 at the Institute of Pathology in Ljubljana, we semiquantitatively evaluated histomorphological changes in veins in nephrectomy specimens of 29 renal allografts with rejection and in 31 control kidneys. The structure of different segments of renal veins was additionally analyzed.

Results

Small interlobular veins were composed of endothelium and basement membrane, similar to capillaries, while the walls of large interlobular and arcuate veins had smooth muscle cell bundles forming the medial layer, similar to large extrarenal veins. In the control group, only focal mononuclear infiltration around small interlobular veins was found (8/31). In rejected kidney allografts, the veins were frequently infiltrated with inflammatory cells, predominantly T lymphocytes and macrophages (29/29). Other changes included thrombosis (16/29), fibrinoid necrosis (7/29), and sclerosis (9/29), and in one case an intimal lipid deposition.

Conclusion

This study, performed on whole explanted kidney specimens, revealed that rejection vasculitis often involved extrarenal and intrarenal veins, showing a whole spectrum of histopathological changes similar to those in arteries. Since large intrarenal veins have a muscle wall, we believe that the term »rejection phlebitis« could be used in renal transplant pathology.

In a single-blinded study, two groups of 10 healthy subjects were given cephapirin or cephalothin by continuous intravenous infusion for 5 days, 0.5 g every 6 hr for the first day and then 1.0 g every 6 hr for 4 days. Eight of the cephalothin subjects and two of the cephapirin subjects developed phlebitis. Phlebitis was more severe in the cephalothin group and developed more rapidly, necessitating vein changes six times more often than in the cephapirin group. The less irritating properties of cephapirin demonstrated in this study indicate it may be the more useful cephalosporin analogue for intravenous therapy.

Previous studies indicated that the risk of thrombophlebitis associated with continuous infusion of intravenous nutrition (IVN) via peripheral veins was reduced when fine-bore catheters, inserted to 15 cm, were used in place of standard intravenous cannulas. An explanation has not been identified, but may be owing to the greater length of the catheters. A randomised controlled study was performed in which a standard nutritional solution was infused via 22G polyurethane catheters inserted to a length of either 5 cm or 15 cm. Catheters were reviewed twice each day and removed when complications occurred, or when IVN was no longer required. There was no significant difference in median time to thrombophlebitis or extravasation, or in daily risk of thrombophlebitis, between insertion lengths. Survival proportions were similar for each length at all times. Catheters inserted into cephalic veins were more prone to thrombophlebitis or extravasation (nine episodes, 14 catheters) than catheters inserted into basilic veins (five episodes, 24 catheters, P = 0.009). The survival proportion was at all times greater when catheter tips lay in basilic veins. Thus, the risk of thrombophlebitis or extravasation was not influenced by the length of catheter within the vein. However, the vein in which the catheter tip lay appeared to influence the development of morbidity.

Background

Peripheral intravenous device (IVD) complications were traditionally thought to be reduced by limiting dwell time. Current recommendations are to resite IVDs by 96 hours with the exception of children and patients with poor veins. Recent evidence suggests routine resite is unnecessary, at least if devices are inserted by a specialised IV team. The aim of this study was to compare the impact of peripheral IVD 'routine resite' with 'removal on clinical indication' on IVD complications in a general hospital without an IV team.

Methods

A randomised, controlled trial was conducted in a regional teaching hospital. After ethics approval, 362 patients (603 IVDs) were randomised to have IVDs replaced on clinical indication (185 patients) or routine change every 3 days (177 patients). IVDs were inserted and managed by the general hospital medical and nursing staff; there was no IV team. The primary endpoint was a composite of IVD complications: phlebitis, infiltration, occlusion, accidental removal, local infection, and device-related bloodstream infection.

Results

IVD complication rates were 68 per 1,000 IVD days (clinically indicated) and 66 per 1,000 IVD days (routine replacement) (P = 0.86; HR 1.03; 95% CI, 0.74-1.43). Time to first complication per patient did not differ between groups (KM with log rank, P = 0.53). There were no local infections or IVD-related bloodstream infections in either group. IV therapy duration did not differ between groups (P = 0.22), but more (P = 0.004) IVDs were placed per patient in the routine replacement (mean, 1.8) than the clinical indication group (mean, 1.5), with significantly higher hospital costs per patient (P < 0.001).

Conclusions

Resite on clinical indication would allow one in two patients to have a single cannula per course of IV treatment, as opposed to one in five patients managed with routine resite; overall complication rates appear similar. Clinically indicated resite would achieve savings in equipment, staff time and patient discomfort. There is growing evidence to support the extended use of peripheral IVDs with removal only on clinical indication.

Registration number

Australian New Zealand Clinical Trials Registry (ANZCTR) Number ACTRN12608000421336.

Objective: To evaluate the effect of heparin on duration of catheter patency and on prevention of complications associated with use of peripheral venous and arterial catheters.

Design: Critical appraisal and meta-analysis of 26 randomised controlled trials that evaluated infusion of heparin intermittently or continuously. Thirteen trials of peripheral venous catheters and two of peripheral arterial catheters met criteria for inclusion.

Main outcome measures: Data on the populations, interventions, outcomes, and methodological quality.

Results: For peripheral venous catheters locked between use flushing with 10 U/ml of heparin instead of normal saline did not reduce the incidence of catheter clotting and phlebitis or improve catheter patency. When heparin was given as a continuous infusion at 1 U/ml the risk of phlebitis decreased (relative risk 0.55; 95% confidence interval 0.39 to 0.77), the duration of patency increased, and infusion failure was reduced (0.88; 0.72 to 1.07). Heparin significantly prolonged duration of patency of radial artery catheters and decreased the risk of clot formation (0.51; 0.42 to 0.61).

Conclusions: Use of intermittent heparin flushes at doses of 10 U/ml in peripheral venous catheters locked between use had no benefit over normal saline flush. Infusion of low dose heparin through a peripheral arterial catheter prolonged the duration of patency but further study is needed to establish its benefit for peripheral venous catheters.

Key messages Despite almost universal use, agreement has not been reached on the need to administer heparin through peripheral intravascular catheters The results of 13 trials on peripheral venous catheters and two trials on peripheral arterial catheters were critically appraised to clarify what evidence supports the use of heparin Flushing peripheral venous catheters locked between use with heparinised saline at 10 U/ml is no more beneficial than flushing with normal saline Heparin significantly prolongs the duration of peripheral arterial catheter patency and decreases the risk of clot formation In peripheral venous catheters heparin added to the infusion at 1 U/ml decreases phlebitis and may prolong duration of catheter patency and decrease infusion failure

Objective: To carry out a randomised controlled clinical trial over a two year period to determine whether a regular change of ventricular catheter every five days could reduce CSF infection and improve outcome.

Methods: 103 patients requiring external ventricular drains for more than five days and with no evidence of concurrent CSF infection were studied. The patients were randomised to regular change of ventricular catheter (every five days) and no change unless clinically indicated.

Results: The CSF infection rates were 7.8% for the catheter change group and 3.8% for the no change group, respectively (rate ratio = 1.80, 95% confidence interval 0.33 to 9.81, p = 0.50). No significant difference was found in intensive care unit stay, ward stay, or clinical outcome between the two groups.

Conclusions: Regular changes of ventricular catheter at five day intervals did not reduce the risk of CSF infection. A single external ventricular drain can be employed for as long as clinically indicated.

The use of peripheral intravenous nutrition using standard Teflon cannulas is limited by a high incidence of thrombophlebitis, with resultant frequent line changes and compromised nutritional therapy. Fine-bore silicone catheters may reduce the incidence of thrombophlebitis; we prospectively compared the silicone catheter with a Teflon cannula in a randomised trial. Seventy-nine surgical patients were randomised to receive peripheral nutrition (10 g nitrogen; 1770 kcal; 650 mOsm/l) either via a Teflon cannula (18G, 4.4 cm long) or via a silicone catheter (23G, 15 cm long). Compared with the group randomised to a standard Teflon cannula, patients fed via a silicone catheter had a significant (P < 0.001) improvement in (a) median time to survival of the first catheter (125 h vs 48 h); (b) incidence of catheter reinsertions (13% vs 75%); and (c) incidence of thrombophlebitis (10% vs 48%). Delivery of a moderately hypertonic nutritional solution through a fine-bore silicone catheter is safe, durable and well tolerated, with a low incidence of complications relative to a Teflon cannula. An expanded role for this catheter in nutritional therapy is feasible, which may reduce the requirement for central venous parenteral nutrition.

Background and Objectives:

Hemodialysis catheters are commonly used when renal replacement therapy is initiated. These catheters have significant complications. Among “locking” solutions used in an attempt to decrease these complications is recombinant tissue plasminogen activator (rt-PA). This systematic review is to determine the efficacy of rt-PA versus heparin, the standard of care.

Materials and Methods:

A systematic review of randomized controlled trials studying rt-PA alone or rt-PA plus heparin versus heparin alone as locking agents for hemodialysis catheters, which included patients needed a temporary hemodialysis catheter for hemodialysis. We identified relevant trials through electronic databases and correspondence with experts. Two investigators independently reviewed potentially eligible trials and extracted data.

Results:

Three trials met the inclusion criteria. One trial reported an improved catheter malfunctioning in patients using rt-PA plus heparin to lock catheters (20.0%) versus heparin alone (34.8%). Another trial reported higher blood flow rate in hemodialysis catheters in patients who received rt-PA (231.6 ± 12.4 mL/min) compared with those who received heparin (206.9 mL/min). The third trial reported formation and weight of clots which were decreased by half in rt-PA group versus heparin group.

Conclusions:

In the few randomized trials that met our inclusion criteria, the use of rt-PA as a locking solution for hemodialysis catheters seems to be associated with fewer adverse events and catheter malfunctioning as compared with heparin. Our systematic review is limited by the few randomized trials addressing our question and the wide variety of outcome measures. Further prospective randomized trials are needed to confirm this conclusion.

Purpose: In order to identify methods for preventing phlebitis caused by intravenous administration of vinorelbine (VNR), we established a procedure for estimating the severity of phlebitis in an animal model.

Methods: Four different factors (administration rate, dilution, flushing, and infusion of fat emulsion) were evaluated for alleviation of phlebitis caused by VNR infusion. VNR was diluted with normal saline to prepare test solutions with concentrations of 0.6 mg/mL or 0.3 mg/mL for infusion into the auricular veins of rabbits. Two days after VNR infusion, the veins were subjected to histopathological examination.

Results: VNR did not cause obvious loss of venous endothelial cells, the most sensitive and common feature of phlebitis, but VNR infusion led to inflammatory cell infiltration, edema, and epidermal degeneration.

Tissue damage was significantly decreased by shortening the administration time and by diluting the VNR solution for infusion from 0.6 mg/mL to 0.3 mg/mL. However, there was no effect of flushing with normal saline after VNR infusion, while treatment with fat emulsion before and after VNR infusion only had a minimal effect.

Conclusion: Rapid infusion and dilution are effective methods of reducing phlebitis caused by the infusion of VNR, but the efficacy of flushing with normal saline or infusion of fat emulsion was not confirmed.

Two studies were performed on a total of 54 patients with staphylococcal infections. Study I compares with phlebitogenic properties of flucloxacillin after intravenous infusions when either saline or sterile water was used as a solvent. No difference was observed between the two solvents, and the frequency of phlebitis for the total material without respect to solvents was 5% after 1 day of treatment and 13% after 2 days. Study II was a double-blind comparison of phlebitis caused by intravenous infusions of either flucloxacillin or cloxacillin. The frequencies of phlebitis were found to be 18 and 13%, respectively. After 2 days of treatment the frequency of phlebitis increased dramatically for both drugs. All infusions were given through a plastic cannula of 5-cm length and 1.2-mm diameter.

To determine the incidence rate of complications associated with vascular catheters in intensive care unit patients and to analyze risk factors for a positive vascular culture, we performed a multicenter study of intensive care unit patients at eight French hospitals. During the study period, 865 intravenous catheters were inserted in 566 patients; 362 (41.8%) were peripheral catheters, and 503 (58.2%) were central catheters. Local complications (i.e., infiltration) occurred significantly more often with peripheral than with central catheters (P less than 0.001); in contrast, fever and bacteremia were significantly more often associated with central than with peripheral catheters (P less than 0.01 and P less than 0.05, respectively). The culture of the vascular-catheter tip was positive for 24% of central catheters (32 of 1,000 catheters days) and for 9% of peripheral catheters (21 of 1,000 catheters days). Staphylococcus epidermidis was the most common microorganism isolated from both peripheral and central catheters, followed by Staphylococcus aureus and Pseudomonas aeruginosa. No significant risk factor associated with positive cultures for peripheral catheters was found by univariate analysis. In contrast, the purpose of the cannula (nutrition and monitoring of central venous pressure), the insertion site (jugular), the dressing type (semipermeable transparent dressing), the antiseptic used to prepare the insertion site (povidone iodine), and routine changing of the intravenous administration set were significantly associated with positive cultures of central catheters. Three factors, duration of catheterization, use of a semipermeable transparent dressing, and the jugular insertion site, were found to be independently associated with positive cultures of central catheters by multivariate analysis.

Purpose: Phlebitis caused by intravenous infusion of antineoplastic agents is one of the critical problems when anticancer therapy is prolonged. We have already reported that both rapid infusion and dilution of the injection solution were effective methods for reducing phlebitis caused by vinorelbine (VNR) in rabbits. The aim of this study was to explore other practical methods for preventing phlebitis caused by VNR and doxorubicin (DXR) in a rabbit model. VNR is often used with cisplatin, and dexamethasone (DEX) has been co-administered for prevention of cisplatin-induced nausea. DXR is used with prednisolone (PSL) in the CHOP regimen for the treatment of non-Hodgkin's lymphoma. Therefore, the present study investigated the prevention of phlebitis due to VNR with DEX and that due to DXR with PSL.

Methods: VNR and DXR were diluted with normal saline to prepare test solutions at concentrations of 0.6 mg/mL and 1.4 mg/mL, respectively. Each test solution was infused into the auricular veins of rabbits. Two days after VNR infusion and three days after DXR infusion, the veins were evaluated histopathologically. The effect of DEX on VNR-induced phlebitis was evaluated by infusion of DEX before or after VNR. The effect of PSL on DXR-induced phlebitis was similarly evaluated by co-infusion of PSL.

Results: The histopathological features of phlebitis caused by the antineoplastic agents differed between VNR and DXR: VNR did not cause the loss of venous endothelial cells, but caused inflammatory cell infiltration, edema, and epidermal degeneration. In contrast, DXR caused the loss of venous endothelial cells and chrondrocyte necrosis. Pre-treatment and post-treatment with DEX significantly decreased VNR-induced phlebitis compared with the control group and pre-treatment was particularly effective. Co-infusion of PSL also significantly decreased phlebitis caused by DXR, but its effect was less marked.

Conclusion: The present findings suggested that pre-treatment with DEX may be a useful method for preventing phlebitis due to VNR, and that co-infusion of PSL has the potential to prevent phlebitis caused by DXR.

In a double-blind study with each patient as his own control, 1 g of cefazolin and 2 g of cephalothin were administered intravenously every 6 h to 20 patients in opposite arms for a period of 48 h each. The degree of phlebitis was significantly more severe with cephalothin than with cefazolin (P < 0.05); however, neither the incidence of phlebitis nor the time of onset of phlebitis was significantly different between the two drugs.

Continuous femoral analgesia provides extended pain relief and improved functional recovery for total knee arthroplasty (TKA). Successful continuous peripheral nerve analgesia depends on the catheter proximity to the target nerve. If the catheter is not close to the nerve, high infusion rates may be required to provide analgesia or analgesia may be sub-optimal. Stimulating catheters may allow more accurate placement of catheters in close proximity to the nerve. This randomized prospective study examined the use stimulating catheters versus non-stimulating catheters in 41 patients undergoing TKA. All patients had intravenous patient controlled anesthesia (IVPCA) for supplementary pain relief. The principal aim of the trial was to examine whether the use of a stimulating catheter allowed the use of lesser amounts of local anesthetics than a non-stimulating catheter. Additional parameters examined included post-operative pain scores, opioid use, side effects and acute functional orthopedic outcomes. Analgesia was good in both groups, but there were no statistically significant differences in the amount of ropivacaine administered; the median amount of ropivacaine given to patients in the stimulating catheter group was 8.2 ml/h vs. 8.8 ml/h for patients with non-stimulating catheters, P = 0.26 (median difference -0.6; 95% confidence interval, -2.3 to 0.6). No significant differences between the treatment groups were noted for the amount of fentanyl dispensed by the IVPCA, numeric pain rating scale scores, acute functional orthopedic outcomes, side effects or amounts of oral opioids consumed.

Implications: For total knee arthroplasty, there seems to be no significant advantage for the use of stimulating catheters over traditional non-stimulating catheters in continuous femoral nerve blocks.

To determine the efficacy of antibiotic catheter lock solution in preventing catheter-related infections, silicone catheters were tunneled and inserted into the jugular veins of 18 rabbits. The catheters were challenged with an intraluminal injection of 105 CFU of slime-producing Staphylococcus epidermidis in 0.1 ml of water. The catheters were maintained on heparin (100 IU/ml) flush for the first 3 days. On day 3, quantitative blood samples for culture were obtained from the catheters and ear veins, which documented catheter-related bacteremia, and the rabbits were randomized to have their catheters flushed as follows: five animals were continued on heparin (100 IU/ml), five animals received vancomycin (3 mg/ml) with heparin (100 IU/ml), and eight animals received 3 mg of minocycline per ml with 30 mg of EDTA per ml (M-EDTA). All animals were killed at day 7. Blood, catheters, jugular veins, and heart valves were cultured quantitatively. Animals maintained on heparin developed catheter-related colonization, bacteremia, septic phlebitis, and endocarditis. Vancomycin-heparin partially prevented catheter colonization, bacteremia, and phlebitis (P = 0.2). M-EDTA completely prevented catheter colonization, catheter-related bacteremia, and phlebitis in all of the animals (P < 0.01). Tricuspid endocarditis was equally prevented by vancomycin-heparin and M-EDTA (P ≤ 0.06). In conclusion, the M-EDTA catheter flush solution was highly efficacious in preventing catheter-related colonization, bacteremia, septic phlebitis, and endocarditis in rabbits.

Background

Tunnelled central venous dialysis catheter use is significantly limited by the occurrence of catheter-related infections. This randomised controlled trial assessed the efficacy of a 48 hour 70% ethanol lock vs heparin locks in prolonging the time to the first episode of catheter related blood stream infection (CRBSI).

Methods

Patients undergoing haemodialysis (HD) via a tunnelled catheter were randomised 1:1 to once per week ethanol locks (with two heparin locks between other dialysis sessions) vs thrice per week heparin locks.

Results

Observed catheter days in the heparin (n=24) and ethanol (n=25) groups were 1814 and 3614 respectively. CRBSI occurred at a rate of 0.85 vs. 0.28 per 1000 catheter days in the heparin vs ethanol group by intention to treat analysis (incident rate ratio (IRR) for ethanol vs. heparin 0.17; 95%CI 0.02-1.63; p=0.12). Flow issues requiring catheter removal occurred at a rate of 1.6 vs 1.4 per 1000 catheter days in the heparin and ethanol groups respectively (IRR 0.85; 95% CI 0.20-3.5 p =0.82 (for ethanol vs heparin).

Conclusions

Catheter survival and catheter-related blood stream infection were not significantly different but there was a trend towards a reduced rate of infection in the ethanol group. This study establishes proof of concept and will inform an adequately powered multicentre trial to definitively examine the efficacy and safety of ethanol locks as an alternative to current therapies used in the prevention of catheter-associated blood stream infections in patients dialysing with tunnelled catheters.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12609000493246

OBJECTIVE:

To determine the relative efficacy and safety of peripheral intravenous locks maintained with heparin saline solutions compared with those maintained with normal saline.

DESIGN:

Randomized, controlled trial comparing the two methods of maintaining peripheral intravenous locks.

SETTING:

Infants in the neonatal intensive care unit (NICU) at Foothills Hospital, Calgary, Alberta.

PATIENTS:

Neonates requiring the maintenance of intravenous locks for medications, primarily antibiotics, were randomly placed in either a heparin saline (n=93) or normal saline (n=93) group.

INTERVENTIONS:

Patients were chosen to receive either heparinized saline (5 units/mL) or normal saline, 0.3 mL in the intravenous catheter every 6 h, administered by nursing staff in a blinded manner.

RESULTS:

There was no difference in catheter lifespan (39±24 h for the heparinized saline group; 34±22 h for the normal saline group) and no difference in the number of intravenous catheters per patient (1.9 heparinized group, 1.6 normal saline group). There were no differences in the reasons for catheter removal, complications at the skin site or systemic bleeding including intracranial hemorrhage between the two groups. The risk of catheter occlusion was inversely correlated with gestational age and the administration of vancomycin and cefotaxime versus ampicillin and gentamicin.

CONCLUSIONS:

Heparin is not required for the maintenance of peripheral intravenous locks in neonates regardless of the solution used. Catheter occlusion is more likely to be associated with a low gestational age and the administration of vancomycin and cefotaxime versus ampicillin and gentamicin.

Objective To evaluate a new and simpler strategy of antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG).

Design Single centre, two arm, randomised, controlled, double blind clinical trial.

Setting Endoscopy unit in Karolinska University Hospital, Stockholm, Sweden, between 3 June 2005 and 31 October 2009.

Participants 234 patients with an indication for PEG who gave informed consent to participate.

Intervention A single 20 ml dose of the oral solution of sulfamethoxazole and trimethoprim (also known as co-trimoxazole or Bactrim; F Hoffmann-La Roche Ltd, Basel, Switzerland) deposited in the PEG catheter immediately after insertion. The control group received standard prophylaxis consisting of a single intravenous dose of 1.5 g cefuroxime (Zinacef; GlaxoSmithKline, London) administered before insertion of the PEG tube.

Main outcome measure Primary outcome was the occurrence of clinically evident wound infection within 14 days after insertion of the PEG catheter. Secondary outcomes were positive bacterial culture and blood tests (highly sensitive C reactive protein and white blood cell count). All randomised patients were included in an intention to treat analysis.

Results Of the 234 patients included in this study, 116 were randomly assigned to co-trimoxazole and 118 to cefuroxime. At follow-up 7-14 days after insertion of the PEG catheter, wound infection was found in 10 (8.6%) patients in the co-trimoxazole group and 14 (11.9%) in the cefuroxime group, which corresponds to a percentage point difference of −3.3% (95% confidence interval −10.9% to 4.5%). The per protocol analysis, which comprised 100 patients in each group, gave similar results—10% and 13% infection in the co-trimoxazole and cefuroxime groups, respectively (percentage point difference −3.0%, 95% CI −11.8% to 5.8%). Both these analyses indicate non-inferiority of co-trimoxazole compared with cefuroxime because the upper bounds of the confidence intervals are lower than the pre-determined non-inferiority margin of 15%. Analyses of the secondary outcomes supported this finding.

Conclusion 20 ml of co-trimoxazole solution deposited in a newly inserted PEG catheter is at least as effective as cefuroxime prophylaxis given intravenously before PEG at preventing wound infections in patients undergoing PEG.

Trial registration Current Controlled Trials ISRCTN18677736.

One of the clinically significant rate-limiting components in even the fastest of intravenous (IV) fluid systems is the tubing connecting the IV catheter to the IV solution container. We evaluated the effect large-bore tubing has on reducing this limitation on fluid flow, measuring gravity and pressurized flow in standard and large-bore tubing alone and when each was connected to an 8 French and 12-,14- and two types of 16-gauge catheters. When combined with an 8 French catheter, large-bore tubing produces a 126% increase in flow under gravity and a 90% increase under pressure. The improvement with the large tubing was less significant as the catheter size decreased. Studies in normovolemic adult volunteers achieved similar results. Large-bore blood tubing and large-bore catheters should be used in all situations where the need for rapid fluid replacement is contemplated.

Background

This abandoned randomised controlled trial assessed the effects of hospitalisation from 24 to 30 weeks gestation for women with a triplet pregnancy on the risk of preterm birth.

Methods

Women with a triplet pregnancy and no other condition necessitating hospital admission were approached for participation in the study, and randomised to either antenatal hospitalisation (hospitalised group), or to routine antenatal care (control group). The randomisation schedule used variable blocks with stratification by parity, and a researcher not involved with clinical care contacted by telephone to determine treatment allocation by opening the next in a series of consecutively numbered, opaque, sealed envelopes. Primary study outcomes were preterm birth (defined as birth less than 37 weeks gestation) and very preterm birth (defined as birth less than 34 weeks gestation), and the development of maternal pregnancy induced hypertension. The trial was ceased prior to achieving the calculated sample size due to difficulties in recruitment. The results of this randomised controlled trial were then combined with the results of another comparing bed rest in women with a triplet pregnancy.

Results

Seven women with a triplet pregnancy were recruited to the trial, with three randomised to the hospitalisation group, and four to the control group. There were no statistically significant differences between the two groups for the primary outcomes birth before 37 weeks (3/3 hospitalisation group versus 4/4 control group; relative risk (RR) not estimable), birth before 34 weeks (3/3 hospitalisation group versus 2/4 control group; RR 2.00 95% Confidence Intervals (CI) 0.75–5.33) and pregnancy induced hypertension (1/3 hospitalisation group versus 1/4 control group; RR 1.33 95%CI 0.13–13.74).

When the results of this trial were incorporated into a meta-analysis with the previous randomised controlled trial assessing hospitalisation and bed rest for women with a triplet pregnancy, (total sample size 26 women and 78 infants), there were no statistically significant differences identified between the two groups.

Conclusion

The results of this trial and meta-analysis suggest no benefit of routine hospitalisation and bed rest for women with a triplet pregnancy to reduce the risk of preterm birth. The adoption or continuation of a policy of routine hospitalisation and bed rest for women with an uncomplicated triplet pregnancy cannot be recommended.

Background

Induction of labour (IOL) is one of the commonest obstetric interventions, with significant impact on both the individual woman and health service delivery. Outpatient IOL is an attractive option to reduce these impacts. To date there is little data comparing outpatient and inpatient IOL methods, and potential safety concerns (hyperstimulation) if prostaglandins, the standard inpatient IOL medications, are used in the outpatient setting. The purpose of this study was to assess feasibility, clinical effectiveness and patient acceptability of outpatient Foley catheter (OPC) vs. inpatient vaginal PGE2 (IP) for induction of labour (IOL) at term.

Methods

Women with an unfavourable cervix requiring IOL at term (N = 101) were randomised to outpatient care using Foley catheter (OPC, n = 50) or inpatient care using vaginal PGE2 (IP, n = 51). OPC group had Foley catheter inserted and were discharged overnight following a reassuring cardiotocograph. IP group received 2 mg/1 mg vaginal PGE2 if nulliparous or 1 mg/1 mg if multiparous. Main outcome measures were inpatient stay (prior to birth, in Birthing Unit, total), mode of birth, induction to delivery interval, adverse reactions and patient satisfaction.

Results

OPC group had shorter hospital stay prior to birth (21.3 vs. 32.4 hrs, p < .001), IP were more likely to achieve vaginal birth within 12 hours of presenting to Birthing Unit (53% vs. 28%, p = .01). Vaginal birth rates (66% OPC Vs. 71% IP), total induction to delivery time (33.5 hrs vs. 31.3 hrs) and total inpatient times (96 hrs OPC Vs. 105 hrs IP) were similar. OPC group felt less pain (significant discomfort 26% Vs 58%, p = .003), and had more sleep (5.8 Vs 3.4 hours, p < .001), during cervical preparation, but were more likely to require oxytocin IOL (88 Vs 59%, p = .001).

Conclusions

OPC was feasible and acceptable for IOL of women with an unfavourable cervix at term compared to IP, however did not show a statistically significant reduction in total inpatient stay and was associated with increased oxytocin IOL.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN:12609000420246.

Backgrounds and Objectives:

Lumbar-to-thoracic advancement of epidural catheter is a safe alternative to direct thoracic placement in children. In this prospective randomized study, success rate of advancement of two different types and gauges of catheter from lumbar-to-thoracic space were studied.

Materials and Methods:

Forty ASA I and II children (up to 6 years) undergoing thoracic or upper-abdominal surgery were allocated to either Group I (18G catheter) or Group II (23G catheter). After induction of general anesthesia a pre-determined length of catheter was inserted. Successful catheter placement was defined as the catheter tip within two segment of surgical incision in radio-contrast study. Intra-operative analgesia was provided by epidural bupivacaine and intravenous morphine. Post-operative analgesia was provided with epidural infusion of 0.1% bupivacaine+1mcg/ml fentanyl.

Observations and Results:

Catheter advancement was successful in 3 cases in Group I and 2 cases in Group II. Five different types of catheter positions were found on X-ray. Negative correlation was found between age and catheter advancement [significance (2-tailed) =0.03]. However, satisfactory post-operative analgesia was obtained in 35 cases. Positive correlation was found between infusion rate, the number of segment of gap between desired level and the level reached [significance (2-tailed) =0.00]. 23G catheter use was associated with more technical complications.

Conclusion:

Advancement of epidural catheter from lumbar to thoracic level was successful in only 10-15% cases but satisfactory analgesia could be provided by increasing the infusion rates.

Atrial fibrillation (AF) is the commonest of all sustained arrhythmias, and most of the patients seeking medical therapy are in the elderly age group. The management of these patients is particularly difficult due to associated comorbidities. Hypertension, congestive heart failure, left ventricular hypertrophy, and coronary artery disease are often present in the elderly patient population, and therefore, antiarrhythmic drugs often fail due to side effects, proarrhythmia, or poor rhythm control. Recently, radiofrequency catheter ablation has been widely performed as an efficient therapy for recurrent, drug-refractory AF. Nevertheless, patients at old age were underrepresented in prior AF ablation trials, and the current guidelines for catheter ablation of AF recommend a noninvasive approach in the elderly patient group due to the lack of clinical data supporting ablation therapy. However, study results of our group and others are suggesting that catheter ablation is a safe and effective treatment for patients over the age of 65 years with symptomatic, drug-refractory AF, and therefore, patients should not be precluded from catheter ablation only on the basis of age. This paper discusses the pharmacological (rhythm control, rate control, and anticoagulation) and catheter management of AF in the elderly population.