RESUMEN
BACKGROUND: Short-term peripheral venous catheter-associated bloodstream infection rates have not been systematically studied in Asian countries, and data on peripheral venous catheter-associated bloodstream infections incidence by number of short-term peripheral venous catheter days are not available. METHODS: Prospective, surveillance study on peripheral venous catheter-associated bloodstream infections conducted from 1 September 2013 to 31 May 2019 in 262 intensive care units, members of the International Nosocomial Infection Control Consortium, from 78 hospitals in 32 cities of 8 countries in the South-East Asia Region: China, India, Malaysia, Mongolia, Nepal, Philippines, Thailand, and Vietnam. For this research, we applied definition and criteria of the CDC NHSN, methodology of the INICC, and software named INICC Surveillance Online System. RESULTS: We followed 83,295 intensive care unit patients for 369,371 bed-days and 376,492 peripheral venous catheter-days. We identified 999 peripheral venous catheter-associated bloodstream infections, amounting to a rate of 2.65/1000 peripheral venous catheter-days. Mortality in patients with peripheral venous catheter but without peripheral venous catheter-associated bloodstream infections was 4.53% and 12.21% in patients with peripheral venous catheter-associated bloodstream infections. The mean length of stay in patients with peripheral venous catheter but without peripheral venous catheter-associated bloodstream infections was 4.40 days and 7.11 days in patients with peripheral venous catheter and peripheral venous catheter-associated bloodstream infections. The microorganism profile showed 67.1% were Gram-negative bacteria: Escherichia coli (22.9%), Klebsiella spp (10.7%), Pseudomonas aeruginosa (5.3%), Enterobacter spp. (4.5%), and others (23.7%). The predominant Gram-positive bacteria were Staphylococcus aureus (11.4%). CONCLUSIONS: Infection prevention programs must be implemented to reduce the incidence of peripheral venous catheter-associated bloodstream infections.
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Infecciones Bacterianas/epidemiología , Infecciones Relacionadas con Catéteres/epidemiología , Cateterismo Periférico/efectos adversos , Infección Hospitalaria/epidemiología , Dispositivos de Acceso Vascular/efectos adversos , Asia/epidemiología , Infecciones Bacterianas/microbiología , Infecciones Bacterianas/mortalidad , Infecciones Bacterianas/terapia , Infecciones Relacionadas con Catéteres/microbiología , Infecciones Relacionadas con Catéteres/mortalidad , Infecciones Relacionadas con Catéteres/terapia , Cateterismo Periférico/mortalidad , Infección Hospitalaria/microbiología , Infección Hospitalaria/mortalidad , Infección Hospitalaria/terapia , Mortalidad Hospitalaria , Humanos , Incidencia , Control de Infecciones , Tiempo de Internación , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: During the past few years, there has been a surge in the use of catheter-directed thrombolysis (CDT) for acute pulmonary embolism (PE), in the form of either standard CDT or ultrasound-assisted CDT (usCDT). This is a systematic review and meta-analysis of all published series on contemporary CDT for acute PE seeking to determine their clinical efficacy, stratifying by PE severity and CDT modality. METHODS: A comprehensive MEDLINE and Embase search was performed to identify studies that reported outcomes of CDT for acute PE published from 2009 to July 2017. Outcomes included clinical success (in-hospital survival with stabilization of hemodynamics, without decompensation or any major complication), in-hospital mortality, major bleeding, right ventricular/left ventricular ratio, and Miller score changes after CDT. Meta-analyses assumed random effects. RESULTS: Twenty studies with 1168 patients were included in the meta-analysis. Available for subgroup analysis were 210 patients with high-risk PE and 945 patients with intermediate-risk PE; 181 patients received CDT using a standard multiside hole catheter, and 850 received usCDT. The pooled average right ventricular/left ventricular improvement and Miller score drop after CDT were 0.30 (95% confidence interval [CI], 0.22-0.39) and 8.8 (95% CI, 7.1-10.5). For high-risk PE, the pooled estimate for clinical success was 81.3% (95% CI, 72.5%-89.1%), the 30-day mortality estimate was 8.0% (95% CI, 3.2%-14.0%), and major bleeding was 6.7% (95% CI, 1.0%-15.3%). For intermediate-risk PE, the pooled estimate for clinical success was 97.5% (95% CI, 95.3%-99.1%), the 30-day mortality was 0% (95% CI, 0%-0.5%), and major bleeding was 1.4% (95% CI, 0.3%-2.8%). In high-risk PE, clinical success for CDT and usCDT was 70.8% (95% CI, 53.4%-85.8%) and 83.1% (95% CI, 68.5%-94.5%), respectively. In intermediate-risk PE, clinical success for CDT and usCDT was 95.0% (95% CI, 88.5%-99.2%) and 97.5% (95% CI, 95.0%-99.4%), respectively. CONCLUSIONS: Catheter thrombolysis has high clinical success rates in both high- and intermediate-risk PE, but higher mortality and bleeding rates should be anticipated in high-risk PE. Ultrasound-assisted thrombolysis may be more effective than standard CDT in the higher risk population.
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Cateterismo Periférico , Fibrinolíticos/administración & dosificación , Embolia Pulmonar/tratamiento farmacológico , Terapia Trombolítica/métodos , Anciano , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/mortalidad , Femenino , Fibrinolíticos/efectos adversos , Hemorragia/inducido químicamente , Humanos , Masculino , Persona de Mediana Edad , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/mortalidad , Embolia Pulmonar/fisiopatología , Factores de Riesgo , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
OBJECTIVE: Catheter-directed interventions (CDIs) are increasingly performed for acute pulmonary embolism (PE) as they are presumed to provide similar therapeutic benefits to systemic thrombolysis (ST) while decreasing the associated complications. The purpose of this study was to compare outcomes between CDI and ST. METHODS: Consecutive patients who underwent CDIs or ST for massive or submassive PE between 2006 and 2016 were identified. Clinical and echocardiographic parameters at baseline and after treatment were recorded. Clinical success was defined as decompensation resolution (or prevention) without major bleeding, stroke, other major treatment-related event, or in-hospital death. The χ2 test and t-test were used for between-groups comparisons. RESULTS: There were 213 patients who received CDIs (standard catheter thrombolysis in 56, ultrasound-assisted thrombolysis in 146, suction thrombectomies in 10, and pharmacomechanical thrombolysis in 1) and 104 patients who received ST (94 high dose [100 mg], 10 low dose [50 mg]). At baseline, CDI and ST groups had comparable echocardiographic parameters, demographics, and comorbidities, except for PE type (massive PE, 8.5% for CDIs vs 69.2% for ST; P < .001), age (60.2 ± 14.9 years for CDIs vs 55.9 ± 17.3 years for ST; P = .023), and renal function (glomerular filtration rate, 78.1 ± 33.7 mL/min/1.73 m2 for CDIs vs 64.1 ± 35.2 mL/min/1.73 m2 for ST; P = .001). Without stratifying per PE type, CDIs had a higher clinical success rate (87.8% vs 66.3%; P < .001) and a lower rate of major bleed (8.0% vs 19.2%; P = .003), stroke (1.4% vs 4.8%; P = .120), and death (1.4% vs 13.5%; P < .001). On stratifying by PE type, there was no difference in clinical success between groups. The mean reduction in right ventricular/left ventricular diameter ratio between baseline and the first post-treatment echocardiographic examination (within 30 days) was significantly higher for CDI (0.27 ± 0.20 vs 0.18 ± 0.15; P = .037). Beyond 30 days, there was no echocardiographic difference between groups. There was no significant difference in clinical outcomes and echocardiographic parameters between standard and ultrasound-assisted CDIs. CONCLUSIONS: CDIs provide improved recovery of right ventricular function compared with ST. Major bleeding and stroke complications may be lower, but larger studies are needed to validate this. CDIs are complementary to ST, and their use should be individualized on the basis of the patients' clinical presentation, risk profile, and local resources.
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Cateterismo Periférico , Fibrinolíticos/administración & dosificación , Embolia Pulmonar/tratamiento farmacológico , Terapia Trombolítica/métodos , Disfunción Ventricular Derecha/fisiopatología , Función Ventricular Derecha , Enfermedad Aguda , Adulto , Anciano , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/mortalidad , Distribución de Chi-Cuadrado , Ecocardiografía , Femenino , Fibrinolíticos/efectos adversos , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/mortalidad , Embolia Pulmonar/fisiopatología , Recuperación de la Función , Estudios Retrospectivos , Factores de Riesgo , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Disfunción Ventricular Derecha/diagnóstico por imagenRESUMEN
OBJECTIVE: Venoarterial extracorporeal membrane oxygenation (ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Owing to the large size of the cannulas inserted via the femoral vessels (≤24-F) required for adequate oxygenation, this procedure could result in significant limb ischemic complications (10%-70%). This study evaluates the results of a distal limb perfusion arterial protocol designed to reduce associated complications. METHODS: We conducted a retrospective institutional review board-approved review of consecutive patients requiring ECMO via femoral cannulation (July 2010-January 2015). To prevent arterial ischemia, a distal perfusion catheter (DPC) was placed antegrade into the superficial femoral artery and connected to the ECMO circuit. Limb perfusion was monitored via near-infrared spectroscopy (NIRS) placed on both calves. Decannulation involved open repair, patch angioplasty, and femoral thrombectomy as needed. RESULTS: A total of 91 patients were placed on ECMO via femoral arterial cannula (16-F to 24-F) for a mean duration of 9 days (range, 1-40 days). A percutaneous DPC was inserted prophylactically at the time of cannulation in 55 of 91 patients, without subsequent ischemia. Of the remaining 36 patients without initial DPC placement, 12 (33% without DPC) developed ipsilateral limb ischemia related to arterial insufficiency, as detected by NIRS and clinical findings. In these patients, the placement of a DPC (n = 7) with or without a fasciotomy, or with a fasciotomy alone (n = 4), resulted in limb salvage; only one patient required subsequent amputation. After decannulation (n = 7), no patients had further evidence of limb ischemia. Risk factors for the development of limb ischemia identified by categorical analysis included lack of DPC at time of cannulation and ECMO cannula size of less than 20-Fr. There was a trend toward younger patient age. Overall ECMO survival rate was 42%, whereas survival in patients with limb ischemia was only 25%. CONCLUSIONS: Limb ischemia complications from ECMO may be decreased by prophylactic placement of an antegrade DPC. Without DPC, continuous monitoring using NIRS may identify limb ischemia, which can be treated subsequently with DPC and or fasciotomy.
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Cateterismo Periférico/instrumentación , Oxigenación por Membrana Extracorpórea/efectos adversos , Isquemia/prevención & control , Pierna/irrigación sanguínea , Perfusión/instrumentación , Dispositivos de Acceso Vascular , Adulto , Anciano , Amputación Quirúrgica , Angioplastia , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/mortalidad , Protocolos Clínicos , Diseño de Equipo , Oxigenación por Membrana Extracorpórea/mortalidad , Fasciotomía , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/fisiopatología , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Perfusión/efectos adversos , Perfusión/mortalidad , Imagen de Perfusión/métodos , Flujo Sanguíneo Regional , Estudios Retrospectivos , Factores de Riesgo , Espectroscopía Infrarroja Corta , Trombectomía , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: We describe an alternate technique for establishing antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest via direct, central cannulation of the innominate artery. METHODS: From 2009 to 2015, 100 elective hemiarch reconstructions for proximal aortic aneurysms were performed under moderate hypothermic circulatory arrest (MHCA). Cerebral perfusion was instituted with ACP via direct cannulation of the innominate artery. RESULTS: Mean patient age was 63 ± 13 years (72 men; 72%). Mean MHCA temperature was 27.3°C ± 1.0°C (median, 28°C). Mean ACP time was 17 ± 4 minutes and mean crossclamp time was 134 ± 42 minutes. Proximal reconstruction included root replacement with composite valved graft (n = 47), valve sparing root reimplantation (n = 16), and aortic valve replacement (n = 19). In-hospital 30-day mortality (n = 1; 1%), stroke (1; 1%), reversible ischemic neurologic deficit (n = 1; 1%), coma (n = 0), and renal failure (n = 1; 1%) rates were low. There was no incidence of injury or dissection of the innominate artery. CONCLUSIONS: Direct, central innominate artery cannulation for ACP yields excellent outcomes. This technique is safe, provides excellent cerebral protection during circulatory arrest and simplifies the circulatory management strategy for elective ascending aortic and hemiarch reconstruction.