RESUMEN
BACKGROUND: The preventable shunt revision rate (PSRR) was recently introduced in pediatric hydrocephalus as a quality metric for shunt surgery. We evaluated the PSRR in an adult hydrocephalus population. METHODS: All ventricular shunt operations (January 1, 2013 to March 31, 2018) performed at a university-based teaching hospital were included. For any index surgery (de novo or revision) resulting in reoperation within 90 days, the index surgery details were collected, and a consensus decision was reached regarding whether the failure had been potentially avoidable. Preventable failure was defined as failure due to infection, malposition, disconnection, migration, or kinking. The 90-day shunt failure rate and PSRR were calculated. Bivariate analyses were performed to evaluate the individual effects of each independent variable on preventable shunt failure. RESULTS: A total of 318 shunt operations had been performed in 245 patients. Most patients were women (62%), with a median age of 48.2 years (interquartile range, 31.2-63.2 years). Most had had ventriculoperitoneal shunts placed (86.5%), and just more than one half were new shunts (51.6%). A total of 53 cases (16.7%) in 42 patients experienced shunt failure within 90 days of the index operation. Of these, 27 failures (8.5% of the total cases; 51% of the failures) were considered potentially preventable. The most common reasons were infection (37%; n = 10) and malposition of the proximal and distal catheters (both 25.9%; n = 7). Age was the only statistically significant difference between the 2 groups, with the patients experiencing preventable shunt failure older than those without preventable shunt failure (51.4 vs. 37.1 years; P = 0.017). CONCLUSIONS: The 90-day PSRR can be applied to an adult population and serve as a quality metric.
Asunto(s)
Derivaciones del Líquido Cefalorraquídeo/normas , Hidrocefalia/cirugía , Indicadores de Calidad de la Atención de Salud , Reoperación/estadística & datos numéricos , Adulto , Anciano , Infecciones Relacionadas con Catéteres/epidemiología , Infecciones Relacionadas con Catéteres/cirugía , Femenino , Hospitales Universitarios , Humanos , Masculino , Persona de Mediana Edad , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/cirugía , Adulto JovenRESUMEN
BACKGROUND: Endocarditis remains one of the most threatening diagnoses in cardiac surgery and is still increasing. Particularly, device-related as well as prosthetic endocarditis appears to be on the rise. Early mortality and periprocedural complications are high jeopardizing the success of surgical efforts. We looked at the development of the numbers and the distribution of endocarditis in an all-comer analysis. METHODS: From 2003 to 2017, 752 patients with endocarditis were transferred to our cardiosurgical institution (mean age 65 ± 13 years; mean logistic EuroSCORE 28.01%; males 74.33%). A total of 89.49% of them were surgically treated; 30.01% redo cases thereof; and 9.17% had been operated previously for acute endocarditis. RESULTS: While the total number of cardiosurgical procedures remained relatively stable throughout the years, 20 patients were admitted in 2003 and 79 in 2017 yielding more than fourfold increase (p < 0.001). Early mortality of all patients was 25.1%. Septic emboli occurred in 23.7% and 43.8% cerebral emboli thereof. A significant increase of aortic, mitral, and tricuspid valves involvement was observed (p < 0.001). An increase of device-related endocarditis was also noted (p < 0.001). CONCLUSION: Endocarditis remains a serious problem with high early mortality and morbidity. The vast increase of electrophysiological device implantations has resulted in an increase of tricuspid valve involvement. Liberalization of endocarditis prophylaxis, that is, more restrictive use of antibiotics in 2007 may have at least partially contributed to an increase of the individual risk to suffer from acute endocarditis. A renaissance of a stricter endocarditis-prophylaxis may thus be considered.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Infecciones Relacionadas con Catéteres/cirugía , Endocarditis Bacteriana/cirugía , Infecciones Relacionadas con Prótesis/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Profilaxis Antibiótica , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Infecciones Relacionadas con Catéteres/diagnóstico , Infecciones Relacionadas con Catéteres/microbiología , Infecciones Relacionadas con Catéteres/mortalidad , Desfibriladores Implantables/efectos adversos , Farmacorresistencia Bacteriana Múltiple , Endocarditis Bacteriana/diagnóstico , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/mortalidad , Femenino , Prótesis Valvulares Cardíacas/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Marcapaso Artificial/efectos adversos , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Relacionadas con Prótesis/mortalidad , Reoperación , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
A 47-year-old woman with a history of radiation enteritis and implantation of a central venous port was admitted to our intensive care unit(ICU) suffering from high fever. She was diagnosed with active infective endocarditis due to catheter-related blood stream infection. Although echocardiography showed a large vegetation on the mitral valve, surgical therapy was postponed for 5 weeks because of intracranial hemorrhage infarction. On the 3rd day after mitral valve repair, she developed consciousness disturbance and computed tomography(CT) revealed acute subdural hematoma of the posterior cranial fossa. Fortunately, she fully recovered from the neurological complication without surgical intervention.
Asunto(s)
Infecciones Relacionadas con Catéteres/cirugía , Infarto Cerebral/diagnóstico por imagen , Endocarditis Bacteriana/cirugía , Hematoma Subdural/diagnóstico por imagen , Hemorragia Posoperatoria/diagnóstico por imagen , Infarto Cerebral/complicaciones , Trastornos de la Conciencia/etiología , Femenino , Humanos , Persona de Mediana Edad , Válvula Mitral/cirugía , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Endoscopic surgery assisted by a navigation system has greatly aided treatment of infected multilocular hydrocephalus, especially in children. CASE REPORT: We describe a 2-year-old boy with multilocular hydrocephalus caused by repeated shunt infection, presenting with fever and vomiting. Magnetic resonance images (MRI) showed extraventricular cysts and severe ventricular deformity. There were three ventriculoperitoneal shunts and one residual ventricular catheter. With a flexible endoscope, we fenestrated the wall of extraventricular cysts and removed the residual catheter. We then used a rigid endoscope to fenestrate ventricular components. Both procedures were guided by electromagnetic (EM) navigation, and hydrocephalus was controlled with one ventricular catheter. CONCLUSION: We have successfully treated a case suffered from infected multilocular hydrocephalus in infants using rigid and flexible endoscopes combined with EM navigation.
Asunto(s)
Infecciones del Sistema Nervioso Central/etiología , Infecciones del Sistema Nervioso Central/cirugía , Endoscopía/métodos , Hidrocefalia/complicaciones , Hidrocefalia/cirugía , Neuronavegación/métodos , Procedimientos Neuroquirúrgicos/métodos , Cirugía Asistida por Computador/métodos , Derivación Ventriculoperitoneal/efectos adversos , Infecciones Relacionadas con Catéteres/diagnóstico por imagen , Infecciones Relacionadas con Catéteres/cirugía , Infecciones del Sistema Nervioso Central/diagnóstico por imagen , Ventrículos Cerebrales/diagnóstico por imagen , Campos Electromagnéticos , Humanos , Hidrocefalia/diagnóstico por imagen , Lactante , Imagen por Resonancia Magnética , Masculino , Tomografía Computarizada por Rayos XRESUMEN
This report reviews the most common surgical interventions and complications of chronic peritoneal dialysis (PD) patients. Based on the current knowledge as well as our experience we detail the role of these surgical procedures. We supplement the reported knowledge in the field with our own experience in this area. The areas discussed include early complications such as surgical wound hemorrhage, bleeding from the catheter, intestinal perforation and urinary bladder perforation, dialysate leakage through the wound, as well as late complications including catheter kinking or occlusion, retention of fluid in the peritoneal recess, hernias and hydrothorax, and encapsulating peritoneal sclerosis. We also briefly cover the surgical aspects of exit-site infection and peritonitis. An understanding by nephrologists of the role for surgical intervention in PD patients will improve their care and outcomes.
Asunto(s)
Infecciones Relacionadas con Catéteres/cirugía , Catéteres de Permanencia/efectos adversos , Diálisis Peritoneal/efectos adversos , Fibrosis Peritoneal/cirugía , Peritonitis/cirugía , Infecciones Relacionadas con Catéteres/fisiopatología , Soluciones para Diálisis/administración & dosificación , Femenino , Estudios de Seguimiento , Humanos , Hidrotórax/etiología , Hidrotórax/cirugía , Masculino , Diálisis Peritoneal/métodos , Diálisis Peritoneal Ambulatoria Continua/efectos adversos , Diálisis Peritoneal Ambulatoria Continua/métodos , Fibrosis Peritoneal/etiología , Fibrosis Peritoneal/fisiopatología , Peritonitis/etiología , Peritonitis/fisiopatología , Calidad de Vida , Medición de Riesgo , Resultado del TratamientoRESUMEN
PURPOSE: To determine if severe neutropenia at the time of chest port insertion is a risk factor for port removal and central catheter-associated bloodstream infection (CCABSI) in pediatric patients. MATERIALS AND METHODS: From May 2007 to June 2015, 183 consecutive patients (mean age, 9.9 y; range, 0.75-21 y) had a port inserted at a single tertiary pediatric center. Seventy-two had severe neutropenia at the time of port insertion (absolute neutrophil count [ANC] range, 0-500/mm3; mean, 185/mm3). Follow-up until port removal or death and CCABSI events were recorded. RESULTS: Within the first 30 days, similar incidences of CCABSI (12.5% of patients with severe neutropenia [n = 9] vs 4.5% of patients without [n = 5]), port removal for infection (2.8% [n = 2] vs 2.7% [n = 3]), and local port infection (2.8% [n = 2] vs 0.9% [n = 1]) were observed in both groups (P > .05), but the rate of CCABSI per 1,000 catheter-days was higher for patients with severe neutropenia (P = .045). Overall, similar incidences of CCABSI (18.1% [n = 13] vs 16.2% [n = 18]), port removal for infection (2.8% [n = 2] vs 7.2% [n = 8]), local port infection (2.8% [n = 2] vs 2.7% [n = 3]), and CCABSIs per 1,000 catheter-days (0.332 vs 0.400) were observed in both groups (P > .05). CONCLUSIONS: Port placement in patients with severe neutropenia can be performed without an increased incidence of port removal for infection. The majority of CCABSIs were successfully treated without port removal.
Asunto(s)
Antineoplásicos/administración & dosificación , Infecciones Relacionadas con Catéteres/cirugía , Cateterismo Venoso Central/efectos adversos , Catéteres de Permanencia , Catéteres Venosos Centrales/efectos adversos , Remoción de Dispositivos , Neoplasias/tratamiento farmacológico , Neutropenia/complicaciones , Centros de Atención Terciaria , Adolescente , Infecciones Relacionadas con Catéteres/diagnóstico , Infecciones Relacionadas con Catéteres/microbiología , Cateterismo Venoso Central/instrumentación , Niño , Preescolar , Diseño de Equipo , Femenino , Humanos , Lactante , Masculino , Neoplasias/complicaciones , Neoplasias/diagnóstico , Neutropenia/diagnóstico , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenAsunto(s)
Infecciones Relacionadas con Catéteres , Catéteres/microbiología , Endocarditis , Atrios Cardíacos , Adulto , Bacteriemia , Infecciones Relacionadas con Catéteres/diagnóstico por imagen , Infecciones Relacionadas con Catéteres/cirugía , Endocarditis/diagnóstico por imagen , Endocarditis/cirugía , Femenino , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/cirugía , Humanos , Infecciones Estafilocócicas , Staphylococcus hominisRESUMEN
Rupture of the peritoneal dialysis (PD) catheter is rare complication. Here, we report a case of catheter rupture that occurred because of exercise after partial catheter reimplantation.A 66-year-old man with a history of end-stage kidney disease secondary to diabetic nephropathy experienced refractory exit-site and tunnel infection. After the infected parts of the catheter were excised, a partial catheter reimplantation was performed. At the time of that surgery, a presternal location was selected for the new exit site, and a titanium extender was used to connect the two catheters. The patient was discharged on postoperative day 3, but was readmitted for a pericatheter leak 5 days later. Fluoroscopy performed to investigate the cause demonstrated a pericatheter leak from the connecting portion between the titanium extender and the catheter.Surgery performed to repair the leak revealed that the catheter had ruptured. We believe that the cause of the rupture was mechanical stress induced by the patient's stretching exercise program. The PD catheter was made of silicone rubber with high elasticity. Even when such resilient materials are used, we recommend that, to avoid PD catheter rupture after partial reimplantation, clinicians should discourage the patient from stretching excessively.
Asunto(s)
Infecciones Relacionadas con Catéteres/cirugía , Catéteres de Permanencia , Nefropatías Diabéticas/terapia , Fallo Renal Crónico/terapia , Ejercicios de Estiramiento Muscular/efectos adversos , Diálisis Peritoneal/instrumentación , Complicaciones Posoperatorias/etiología , Falla de Prótesis/etiología , Anciano , Humanos , Masculino , Estrés MecánicoRESUMEN
We present a case of successful interventional laser-assisted extraction of an endovascularly trapped long-term implanted ventriculoatrial shunt in a patient with shunt-associated septicemia. This approach is based on modified techniques for explantation of pacemaker leads and might be considered an additional option for extraction of otherwise nonremovable trapped endovascular catheters in experienced centers.
Asunto(s)
Infecciones Relacionadas con Catéteres/cirugía , Derivaciones del Líquido Cefalorraquídeo/efectos adversos , Remoción de Dispositivos/métodos , Terapia por Láser/métodos , Adulto , Antibacterianos/uso terapéutico , Femenino , Atrios Cardíacos/cirugía , Humanos , Venas Yugulares/cirugía , Marcapaso Artificial , Sepsis/etiología , Resultado del Tratamiento , Vena Cava Superior/cirugíaRESUMEN
BACKGROUND: Rapidly growing mycobacteria (RGM) infections in pediatric oncology patients have not been completely characterized. METHODS: We reviewed medical records of oncology patients at St. Jude Children's Research Hospital (St. Jude) from 1990 to 2010 with RGM infections and summarized the results of previously published cases. RESULTS: Twenty-five St. Jude patients had 27 episodes of infection. Approximately half of the cases occurred in patients with hematological malignancies and in males; infections were more common in white patients. Most patients were not neutropenic or lymphopenic. The most common causative species were Mycobacterium chelonae, Mycobacterium abscessus, and Mycobacterium fortuitum. Most isolates were susceptible to amikacin and clarithromycin; all were susceptible to at least 1 of these. Treatment regimens varied considerably, particularly with respect to the duration of antimicrobial chemotherapy. Two St. Jude patients died; both had pulmonary infections. The literature search identified an additional 58 cases of infection. Localized catheter-associated infections were more common than bloodstream infections in the current series than in previous reports, and outbreaks were not recognized. Otherwise, the demographic and clinical characteristics of patients were similar. CONCLUSIONS: Localized catheter-associated infections were most common in this largest reported single center experience reported to date. Pulmonary infection is uncommon in children but, as in adults, has a high mortality rate. Relatively short-term antimicrobial treatment and surgical debridement of infected tissue, if present, may be as effective for catheter-associated infections as prolonged antimicrobial use and may reduce adverse drug effects in these patients, who are vulnerable to drug-drug interactions and toxicity.
Asunto(s)
Antiinfecciosos/administración & dosificación , Antiinfecciosos/uso terapéutico , Desbridamiento/estadística & datos numéricos , Huésped Inmunocomprometido/efectos de los fármacos , Infecciones por Mycobacterium/clasificación , Infecciones por Mycobacterium/tratamiento farmacológico , Infecciones por Mycobacterium/cirugía , Neoplasias/complicaciones , Adolescente , Amicacina/farmacología , Amicacina/uso terapéutico , Antiinfecciosos/farmacología , Infecciones Relacionadas con Catéteres/clasificación , Infecciones Relacionadas con Catéteres/tratamiento farmacológico , Infecciones Relacionadas con Catéteres/cirugía , Niño , Preescolar , Claritromicina/farmacología , Claritromicina/uso terapéutico , Femenino , Humanos , Lactante , Enfermedades Pulmonares/terapia , Masculino , Pruebas de Sensibilidad Microbiana , Mycobacterium/crecimiento & desarrollo , Mycobacterium/aislamiento & purificación , Mycobacterium/patogenicidad , Estudios RetrospectivosRESUMEN
BACKGROUND: The occurrence of mycotic pseudoaneurysms of the subclavian artery (SA) is rare. Only 3 cases of a combined open and endovascular treatment of true SA aneurysms have been reported. Conventional treatment for SA pseudoaneurysms is invasive thoracic surgery. Ours is a novel approach for mycotic pseudoaneurysm. METHODS: A 72 year-old man with gastric cancer developed vocal cord paralysis because of a mycotic pseudoaneurysm of the right SA, after Hickman line insertion. Because of the close proximity between the pseudoaneurysm at the origin of the SA and the innominate and common carotid arteries, a combined endovascular and open carotid SA bypass was performed. RESULTS: At 1-year follow-up, he recovered well, remained cancer-free, with resolution of the pseudoaneurysm. Both the anastomoses and stents remained widely patent. CONCLUSIONS: This case represents the first reported successful treatment of a mycotic SA pseudoaneurysm through a combined open bypass and covered stenting, with encouraging outcomes at 1-year follow-up.
Asunto(s)
Aneurisma Falso/cirugía , Aneurisma Infectado/cirugía , Implantación de Prótesis Vascular/métodos , Arterias Carótidas/cirugía , Infecciones Relacionadas con Catéteres/cirugía , Procedimientos Endovasculares/métodos , Arteria Subclavia/cirugía , Anciano , Aneurisma Falso/diagnóstico , Aneurisma Falso/microbiología , Aneurisma Infectado/diagnóstico , Aneurisma Infectado/microbiología , Antibacterianos/uso terapéutico , Antineoplásicos/administración & dosificación , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Infecciones Relacionadas con Catéteres/diagnóstico , Infecciones Relacionadas con Catéteres/microbiología , Cateterismo Venoso Central/efectos adversos , Procedimientos Endovasculares/instrumentación , Humanos , Masculino , Stents , Neoplasias Gástricas/tratamiento farmacológico , Arteria Subclavia/diagnóstico por imagen , Arteria Subclavia/microbiología , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVE/BACKGROUND: The aim of this study was to evaluate the clinical features and outcomes of catheter related central venous thrombosis and whether a surgical approach can be an effective treatment modality in selected cases that are refractory to conservative management. METHODS: This was a retrospective review of the 46 consecutive patients who were suspected of having central venous catheter related infected deep venous thrombosis and who met the eligibility criteria. RESULTS: Conservative management achieved clinical improvement in 26 (56.5%) patients and failed in 20 (43.5%), of whom surgical thrombectomy was performed in 13. The remaining seven patients died before surgery could be performed or their clinical condition was too poor. Apart from one case of wound hematoma (7.7%), post-operative complications that related to the surgical procedure were not observed. Patency of the involved vein was re-established in 12 of the 13 (92.3%) surgically treated patients, and clinical improvement was achieved in 11 (84.6%). In particular, the five patients whose blood cultures revealed Candida species exhibited prompt defervescence after surgical thrombectomy. CONCLUSION: Although conservative management is the first therapy of choice in patients with central venous catheter related infected thrombosis, surgical treatment that removes the septic material can be regarded as a last resort in critically ill patients with septic thrombophlebitis that is refractory to conservative management.
Asunto(s)
Infecciones Relacionadas con Catéteres/cirugía , Cateterismo Venoso Central/efectos adversos , Catéteres Venosos Centrales/efectos adversos , Remoción de Dispositivos , Sepsis/cirugía , Trombectomía , Tromboflebitis/cirugía , Trombosis Venosa Profunda de la Extremidad Superior/cirugía , Anciano , Anciano de 80 o más Años , Infecciones Relacionadas con Catéteres/diagnóstico , Infecciones Relacionadas con Catéteres/microbiología , Infecciones Relacionadas con Catéteres/mortalidad , Cateterismo Venoso Central/instrumentación , Cateterismo Venoso Central/mortalidad , Remoción de Dispositivos/efectos adversos , Remoción de Dispositivos/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Sepsis/diagnóstico , Sepsis/microbiología , Sepsis/mortalidad , Trombectomía/efectos adversos , Trombectomía/mortalidad , Tromboflebitis/diagnóstico , Tromboflebitis/microbiología , Resultado del Tratamiento , Trombosis Venosa Profunda de la Extremidad Superior/diagnóstico , Trombosis Venosa Profunda de la Extremidad Superior/microbiología , Trombosis Venosa Profunda de la Extremidad Superior/mortalidadRESUMEN
Catheter-related right atrial thrombosis (CRAT) is an underreported and potentially life-threatening complication of central venous catheter in hemodialysis patients. The accurate incidence is unknown, with reported rates ranging from 2 to 12.8% [1] in series, up to 29% [2] in a postmortem prospective study, and high mortality rates (18%) [1]. The optimal treatment for CRAT is controversial and nonsystematized, including anticoagulation, thrombolysis, and surgical thrombectomy. We report two cases of CRAT in dialysis patients, who underwent surgical thrombectomy. One case required reintervention because of recurrence, a first reported case in hemodialysis population.
Asunto(s)
Anticoagulantes/uso terapéutico , Infecciones Relacionadas con Catéteres , Cateterismo Venoso Central/efectos adversos , Cardiopatías , Diálisis Renal , Infecciones Estafilocócicas , Trombectomía , Trombosis , Adulto , Pruebas de Coagulación Sanguínea , Infecciones Relacionadas con Catéteres/diagnóstico , Infecciones Relacionadas con Catéteres/microbiología , Infecciones Relacionadas con Catéteres/cirugía , Cateterismo Venoso Central/métodos , Femenino , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/fisiopatología , Cardiopatías/diagnóstico , Cardiopatías/etiología , Cardiopatías/fisiopatología , Cardiopatías/cirugía , Humanos , Fallo Renal Crónico/terapia , Persona de Mediana Edad , Diálisis Renal/efectos adversos , Diálisis Renal/instrumentación , Diálisis Renal/métodos , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/etiología , Infecciones Estafilocócicas/cirugía , Trombectomía/efectos adversos , Trombectomía/métodos , Trombosis/diagnóstico , Trombosis/etiología , Trombosis/fisiopatología , Trombosis/cirugía , Resultado del Tratamiento , UltrasonografíaAsunto(s)
Pared Abdominal/cirugía , Tejido Adiposo/cirugía , Infecciones Relacionadas con Catéteres/cirugía , Catéteres de Permanencia/microbiología , Procedimientos Quirúrgicos Dermatologicos/métodos , Remoción de Dispositivos/métodos , Diálisis Peritoneal/efectos adversos , Tejido Adiposo/microbiología , Anciano , Bacterias/aislamiento & purificación , Infecciones Relacionadas con Catéteres/diagnóstico , Infecciones Relacionadas con Catéteres/microbiología , Catéteres de Permanencia/efectos adversos , Femenino , Humanos , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana Edad , Diálisis Peritoneal/instrumentación , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
BACKGROUND: Cannulation of the radial artery is frequently performed for invasive hemodynamic monitoring. Complications arising from indwelling catheters have been described in small case series; however, their surgical management is not well described. Understanding the presentation and management of such complications is imperative to offer optimal treatment, particularly because the radial artery is increasingly accessed for percutaneous coronary interventions. METHODS: We conducted a retrospective review to identify patients who underwent surgical intervention for complications arising from indwelling radial artery catheters from 1997 to 2011. RESULTS: We identified 30 patients who developed complications requiring surgical intervention. These complications were categorized into ischemic and nonischemic, with 15 patients identified in each cohort. All patients presenting with clinical hand or digital ischemia underwent thrombectomy and revascularization. Complications in the nonischemic group included three patients with deep abscesses with concomitant arterial thrombosis, two with deep abscesses alone, and 10 with pseudoaneurysms. Treatment strategy in this group varied with the presenting pathology. Among the entire case series, three patients required reintervention after the initial surgery, all in individuals initially presenting with ischemia who developed recurrent thrombosis of the radial artery. There were no digital or hand amputations in this series. However, the overall in-hospital mortality in these patients was 37%, reflecting the severity of illness in this patient cohort. Three patients who were positive for heparin-induced thrombocytopenia antibody had 100% mortality compared with those who were negative (P = .04, Fisher exact test). In-hospital mortality was higher in patients presenting with initial ischemia than in those with nonischemic complications (53% vs 20%; P = .06). Among 10 patients who presented with pseudoaneurysms, five (50%) were septic at presentation with positive blood cultures, and six (60%) had positive operating room cultures. Staphylococcus aureus was identified as the causative organism in all of these patients. CONCLUSIONS: Complications of radial artery cannulation requiring surgical intervention can represent infectious and ischemic sequelae and have the potential to result in major morbidity, including digital or hand amputation and sepsis, or death. Although surgical treatment is successful and often required in these patients to treat severe hand ischemia, hemorrhage, or vascular infection, these complications tend to occur in critically ill hospitalized patients with an extremely high mortality. This must be taken into consideration when planning surgical intervention in this patient cohort. Finally, radial arterial cannulation sites should not be overlooked when searching for occult septic sources in critically ill patients.
Asunto(s)
Absceso/cirugía , Infecciones Relacionadas con Catéteres/cirugía , Cateterismo Periférico/efectos adversos , Catéteres de Permanencia/efectos adversos , Mano/irrigación sanguínea , Arteria Radial/cirugía , Dispositivos de Acceso Vascular/efectos adversos , Enfermedades Vasculares/cirugía , Procedimientos Quirúrgicos Vasculares , Absceso/diagnóstico , Absceso/etiología , Absceso/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma Falso/etiología , Aneurisma Falso/cirugía , Aneurisma Infectado/etiología , Aneurisma Infectado/cirugía , Infecciones Relacionadas con Catéteres/diagnóstico , Infecciones Relacionadas con Catéteres/etiología , Infecciones Relacionadas con Catéteres/mortalidad , Cateterismo Periférico/instrumentación , Cateterismo Periférico/mortalidad , Femenino , Dedos/irrigación sanguínea , Mortalidad Hospitalaria , Humanos , Isquemia/etiología , Isquemia/cirugía , Masculino , Persona de Mediana Edad , Arteria Radial/diagnóstico por imagen , Recurrencia , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Trombectomía , Trombosis/etiología , Trombosis/cirugía , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Enfermedades Vasculares/diagnóstico , Enfermedades Vasculares/etiología , Enfermedades Vasculares/mortalidadRESUMEN
This case report describes a patient, who had a thoracic epidural abscess without neurological deficits. The patient had epidural analgesia due to a flail chest trauma. After 14 days he developed radicular pain during bolus injection through the catheter, as well as fever and elevated white cell count and C reactive protein. An acute magnetic resonance imaging revealed a thoracic epidural abscess. The initial treatment was high dose antibiotic therapy followed by an acute surgical laminectomy. The patient never developed any neurological signs and was kept on high dose oral opioids and gabapentin in order to secure sufficient analgesia.
Asunto(s)
Analgesia Epidural/efectos adversos , Absceso Epidural/microbiología , Analgésicos/administración & dosificación , Analgésicos/uso terapéutico , Antibacterianos/administración & dosificación , Antibacterianos/uso terapéutico , Infecciones Relacionadas con Catéteres/diagnóstico , Infecciones Relacionadas con Catéteres/tratamiento farmacológico , Infecciones Relacionadas con Catéteres/microbiología , Infecciones Relacionadas con Catéteres/cirugía , Absceso Epidural/diagnóstico , Absceso Epidural/tratamiento farmacológico , Absceso Epidural/cirugía , Humanos , Laminectomía , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Dolor/etiología , Médula Espinal/microbiología , Médula Espinal/cirugía , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/tratamiento farmacológico , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/cirugía , Staphylococcus epidermidis/aislamiento & purificación , Resultado del TratamientoRESUMEN
BACKGROUND: Studies on the implantation of care routines showed reduction on EVD catheter-related infections rates; however zero tolerance is difficult to be achieved. The objective of this study was to assess the impact of an educational intervention on the maximal reduction on rates of EVD-related infections. METHODOLOGY/PRINCIPAL FINDINGS: The quasi-experimental (before-after intervention) study occurred in two phases: pre-intervention, from April 2007 to July 2008, and intervention, from August 2008 to July 2010. Patients were followed for 30 days after the removal of the EVD, and EVD-related infections were considered as only those with laboratorial confirmation in the CSF. Observations were made of the care of the EVD and compliance with Hygiene of the Hands (HH), a routine of care was drawn up, training was given, and intervention was made to reduce the time the EVD catheter remained in place. RESULTS: during the study, 178 patients were submitted to 194 procedures, corresponding to 1217 EVD catheters-day. Gram-negative agents were identified in 71.4% of the infections during the pre-intervention period and in 60% during the intervention period. During the study, EVD-related infection rates were reduced from 9.5% to 4.8% per patient, from 8.8% to 4.4% per procedure, and the incidence density dropped from 14.0 to 6.9 infections per 1000 catheters-day (p = 0.027). The mortality reduced 12% (from 42% to 30%). CONCLUSIONS/SIGNIFICANCE: During one year after the fourth intervention, no microbiologically identified infection was documented. In light of these results, educational intervention proved to be a useful tool in reducing these rates and showed also impact on mortality.
Asunto(s)
Infecciones Relacionadas con Catéteres/prevención & control , Catéteres de Permanencia/microbiología , Ventrículos Cerebrales/cirugía , Ventriculitis Cerebral/prevención & control , Infecciones por Bacterias Gramnegativas/prevención & control , Higiene de las Manos/organización & administración , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Infecciones Relacionadas con Catéteres/microbiología , Infecciones Relacionadas con Catéteres/cirugía , Ventrículos Cerebrales/microbiología , Ventriculitis Cerebral/microbiología , Ventriculitis Cerebral/cirugía , Niño , Drenaje/instrumentación , Drenaje/métodos , Educación/organización & administración , Educación/estadística & datos numéricos , Femenino , Infecciones por Bacterias Gramnegativas/microbiología , Infecciones por Bacterias Gramnegativas/cirugía , Higiene de las Manos/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos , Persona de Mediana Edad , Neurología , Garantía de la Calidad de Atención de Salud/tendenciasRESUMEN
PURPOSE: As peritoneal dialysis (PD) is the preferred long-term dialysis modality in the pediatric population, we sought to identify risk factors for mortality and reoperation. METHODS: A retrospective review of patients undergoing PD catheter insertions at a single center from 1994-2009 was performed. The following variables were evaluated: age (<1 year), comorbidities, omentectomy, concomitant gastrostomy, and laparoscopic technique. Multivariable Cox regressions analyses were used to evaluate patient survival and reoperation-free survival of PD catheters. RESULTS: 207 patients with a median age of 10 years underwent PD insertion. Mortality was 7% with a median follow up of 72 months. Reoperation for malfunction and infection was required in 49% of patients with a median PD catheter survival of 11 months. Reoperation for hernias occurred in 14% of patients. Multivariate Cox regressions analyses identified age <1 year, lack of omentectomy, concomitant gastrostomy, and prematurity as variables significantly associated with higher rates of mortality or reoperation. CONCLUSIONS: In this large study of pediatric patients undergoing PD, higher complication rates were noted in infants less than one year of age. Concomitant gastrostomy was associated with a higher rate of reoperation for infection. Failure to perform omentectomy was associated with a higher rate of catheter failure.