Vanessa Cartier

Hospital-wide surveillance of catheter-related bloodstream infection: from the expected to the unexpected.

Catheter-related bloodstream infections (CRBSIs) are among the most frequent healthcare-associated infections and cause considerable morbidity, mortality, and resource use. CRBSI surveillance serves quality improvement, but is often restricted to intensive care units (ICUs). We conducted a four-month prospective cohort study of all non-cuffed central venous catheters (CVCs) to design an efficient CRBSI surveillance and prevention programme. CVCs were assessed on a daily basis for ward exposure time, care parameters, and the occurrence of laboratory-confirmed CRBSI. Overall, 248 patients with 426 CVCs accounted for 3567 CVC-days (median: 5) and 15 CRBSI episodes. CVCs were inserted by anaesthetists, ICU physicians and internists in 45%, 47%, and 8% of cases, respectively. CVC utilisation rates for intensive care, internal medicine, non-abdominal surgery and abdominal surgery were 29.8, 3.8, 1.7 and 4.9 per 100 patient-days, respectively. Fourteen percent of patients changed wards while having a CVC in place, so spending CVC-days at risk within multiple departments. CRBSI incidence densities for ICU, internal medicine, surgery and abdominal surgery were 5.6, 1.9, 2.4 and 7.7 per 1000 CVC-days at risk, respectively. In a univariate Cox proportional hazards model, the high CRBSI rate in abdominal surgery was associated with longer CVC duration, frequent use of parenteral nutrition and CVC insertion by anaesthetists. CRBSI numbers were insufficient to perform a multivariate analysis. Our surveillance revealed similar CRBSI rates in both ICU and non-ICU departments, and when frequent ward transfers occurred. Hospital-wide CRBSI surveillance is advisable when a large proportion of CVC-days occur outside the ICU.

Risk factors of acute kidney injury according to RIFLE criteria after lung cancer surgery.

BACKGROUND Perioperative acute kidney injury (AKI) is associated with increased mortality and morbidity. Our aim was to evaluate the incidence and determinants of AKI using the risk, injury, failure, loss of function, and end-stage kidney disease (RIFLE) criteria in thoracic surgical patients. METHODS We retrospectively analyzed a cohort of patients undergoing lung cancer surgery from 1996 to 2009. Patient management was protocol-driven, and postoperative complications were prospectively collected. The primary outcome was AKI within 3 days after surgery. A variety of patient comorbidities and operative characteristics were evaluated as potential predictors of AKI using a multiple logistic regression model. RESULTS Complete data were obtained from 1,345 patients, and the incidence of AKI was 6.8%. Four independent risk factors for AKI were identified: American Society of Anesthesiologists classes 3 and 4 (odds ratio [OR] 2.60, 95% confidence interval [CI]: 1.03 to 6.55), forced expiratory volume in 1 second (OR 0.55, 95% CI: 0.32 to 0.96), the use of vasopressors (OR 1.015, 95% CI: 0.998 to 1.035), and the duration of anesthesia (OR 1.044, 95% CI: 1.001 to 1.008). Patients who experienced AKI were more frequently admitted to the intensive care unit (24.2% versus 3.5% for patients without AKI, p < 0.05); they had increased mortality (19.8% versus 1.1%, p < 0.05) and a threefold to fourfold higher incidence of cardiopulmonary complications. CONCLUSIONS The RIFLE classification is a valuable tool to assess AKI after lung cancer surgery. The severity of perioperative renal impairment is associated with increased mortality and morbidity.

Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection

Central line-associated bloodstream infection (CLABSI) is the major complication of central venous catheters (CVC). The aim of the study was to test the effectiveness of a hospital-wide strategy on CLABSI reduction. Between 2008 and 2011, all CVCs were observed individually and hospital-wide at a large university-affiliated, tertiary care hospital. CVC insertion training started from the 3rd quarter and a total of 146 physicians employed or newly entering the hospital were trained in simulator workshops. CVC care started from quarter 7 and a total of 1274 nurses were trained by their supervisors using a web-based, modular, e-learning programme. The study included 3952 patients with 6353 CVCs accumulating 61,366 catheter-days. Hospital-wide, 106 patients had 114 CLABSIs with a cumulative incidence of 1.79 infections per 100 catheters. We observed a significant quarterly reduction of the incidence density (incidence rate ratios [95% confidence interval]: 0.92 [0.88–0.96]; P<0.001) after adjusting for multiple confounders. The incidence densities (n/1000 catheter-days) in the first and last study year were 2.3/1000 and 0.7/1000 hospital-wide, 1.7/1000 and 0.4/1000 in the intensive care units, and 2.7/1000 and 0.9/1000 in non-intensive care settings, respectively. Median time-to-infection was 15 days (Interquartile range, 8-22). Our findings suggest that clinically relevant reduction of hospital-wide CLABSI was reached with a comprehensive, multidisciplinary and multimodal quality improvement programme including aspects of behavioural change and key principles of good implementation practice. This is one of the first multimodal, multidisciplinary, hospital-wide training strategies successfully reducing CLABSI.

Hospital-wide survey of the use of central venous catheters

There are few data on indications for central venous catheter (CVC) use. We conducted an observational, hospital-wide prospective cohort study to quantify the indications for catheter placement over dwell time and to investigate agreement between healthcare workers (HCWs) on CVC use. Catheter use was observed by on-site visits, HCW interviews, and screening of patient charts. A total of 378 CVCs were inserted in 292 patients, accounting for 2704 catheter-days. Of these, 93% CVCs were multilumen catheters and 70% were placed in the intensive care unit (ICU). Median dwell time (interquartile range) was 5 (2-9) days overall, and 4 (2-7) and 8 (3-15) in the ICU and non-ICU settings, respectively. The mean number of specified indications for CVC use per day was 1.7 (1.9 for ICU and 1.5 for non-ICU; P<0.001). The most frequent reason (49%) for catheter use was prolonged (>7 days) antibiotic therapy followed by parenteral nutrition (22.3%). A total of 130 catheter-days (4.8%) were unnecessary with a higher proportion in non-ICU settings (6.6%). In 94% of cases, there was agreement among HCWs on indications for CVC use. However, 35 on-site visits (8.3%) in non-ICU settings revealed that neither the nurse nor the treating physician knew why the catheter was in place. ICU catheters have a short dwell time but are utilised more often, whereas catheters in non-ICU settings show a reverse characteristic. Prevention measures targeting catheter care are more likely to be successful in non-ICU settings.

Preoperative diastolic function predicts the onset of left ventricular dysfunction following aortic valve replacement in high-risk patients with aortic stenosis

IntroductionLeft ventricular (LV) dysfunction frequently occurs after cardiac surgery, requiring inotropic treatment and/or mechanical circulatory support. In this study, we aimed to identify clinical, surgical and echocardiographic factors that are associated with LV dysfunction during weaning from cardiopulmonary bypass (CPB) in high-risk patients undergoing valve replacement for aortic stenosis.MethodsPerioperative data were prospectively collected in 108 surgical candidates with an expected operative mortality ≥9%. All anesthetic and surgical techniques were standardized. Reduced LV systolic function was defined by an ejection fraction <40%. Diastolic function of the LV was assessed using standard Doppler-derived parameters, tissue Doppler Imaging (TDI) and transmitral flow propagation velocity (Vp).ResultsDoppler-derived pulmonary flow indices and TDI could not be obtained in 14 patients. In the remaining 94 patients, poor systolic LV was documented in 14% (n = 12) and diastolic dysfunction in 84% of patients (n = 89), all of whom had Vp <50 cm/s. During weaning from CPB, 38 patients (40%) required inotropic and/or mechanical circulatory support. By multivariate regression analysis, we identified three independent predictors of LV systolic dysfunction: age (Odds ratio [OR] = 1.11; 95% confidence interval (CI), 1.01 to 1.22), aortic clamping time (OR = 1.04; 95% CI, 1.00 to 1.08) and Vp (OR = 0.65; 95% CI, 0.52 to 0.81). Among echocardiographic measurements, Vp was found to be superior in terms of prognostic value and reliability. The best cut-off value for Vp to predict LV dysfunction was 40 cm/s (sensitivity of 72% and specificity 94%). Patients who experienced LV dysfunction presented higher in-hospital mortality (18.4% vs. 3.6% in patients without LV dysfunction, P = 0.044) and an increased incidence of serious cardiac events (81.6 vs. 28.6%, P < 0.001).ConclusionsThis study provides the first evidence that, besides advanced age and prolonged myocardial ischemic time, LV diastolic dysfunction characterized by Vp ≤ 40 cm/sec identifies patients who will require cardiovascular support following valve replacement for aortic stenosis.

Titrated Sedation with Propofol for Medical Thoracoscopy: A Feasibility and Safety Study

Background: Bispectral index (BIS) is a valuable tool for assessing the depth of sedation and guiding the administration of sedative drugs. We previously demonstrated the benefits of BIS-guided propofol sedation in patients undergoing flexible bronchoscopy. Objective: To examine the feasibility and safety profile of propofol sedation in patients undergoing medical thoracoscopy (MT). Methods: Patients undergoing MT for diagnostic evaluation or treatment of pleuropulmonary diseases were enrolled over a 2-year period. Nurses and chest physicians were trained by anesthetists to provide analgosedation, to detect and correct cardiopulmonary disturbances. The level of sedation was optimized individually by titrating the propofol infusion according to the BIS and clinical evaluation. Patients’ clinical data, procedure time, medications and any adverse events were recorded. Results: Fifty-three patients (60% male) with a median age of 62 years (range 19–84 years) underwent MT. The operative procedure lasted a median time of 28 min (range 9–112 min). The median doses of anesthetic drugs were 145 mg of propofol (range 20–410 mg) and 84 µg of fentanyl (range 0–225 µg). Hemodynamic disturbances occurred in 39 patients (bradycardia n = 4, tachycardia n = 12, hypotension n = 34) and required drug administration in only 4 cases. Hypoxemic events (n = 4) resolved upon gentle patient stimulation (verbal command, chin lift, oral cannula). All patients could be discharged from the recovery unit within 105 min after the procedure. Conclusions: BIS-guided propofol sedation is a safe method that might replace midazolam sedation in MT and can be managed by well-trained nonanesthesiologist personnel.

Clinical Review: Management of weaning from cardiopulmonary bypass after cardiac surgery

A sizable number of cardiac surgical patients are difficult to wean off cardiopulmonary bypass (CPB) as a result of structural or functional cardiac abnormalities, vasoplegic syndrome, or ventricular dysfunction. In these cases, therapeutic decisions have to be taken quickly for successful separation from CPB. Various crisis management scenarios can be anticipated which emphasizes the importance of basic knowledge in applied cardiovascular physiology, knowledge of pathophysiology of the surgical lesions as well as leadership, and communication between multiple team members in a high-stakes environment. Since the mid-90s, transoesophageal echocardiography has provided an opportunity to assess the completeness of surgery, to identify abnormal circulatory conditions, and to guide specific medical and surgical interventions. However, because of the lack of evidence-based guidelines, there is a large variability regarding the use of cardiovascular drugs and mechanical circulatory support at the time of weaning from the CPB. This review presents key features for risk stratification and risk modulation as well as a standardized physiological approach to achieve successful weaning from CPB.

Impact of anesthesia technique on the incidence of major complications after open aortic abdominal surgery: a cohort study

STUDY OBJECTIVE To determine the risk factors of perioperative complications and the impact of intrathecal morphine (ITM) in major vascular surgery. DESIGN Retrospective analysis of a prospective cohort. SETTINGS Operating room, intensive care unit, and Postanesthesia Care Unit of a university hospital. MEASUREMENTS Data from 595 consecutive patients who underwent open abdominal aortic surgery between January 1997 and December 2011 were reviewed. Data were stratified into three groups based on the analgesia technique delivered: systemic analgesia (Goup SA), thoracic epidural analgesia (Group TEA), and intrathecal morphine (Group ITM). Preoperative patient characteristics, perioperative anesthetic and medical interventions, and major nonsurgical complications were recorded. MAIN RESULTS Patients managed with ITM (n=248) and those given thoracic epidural analgesia (n=70) required lower doses of intravenous (IV) sufentanil intraoperatively and were extubated sooner than those who received systemic analgesia (n=270). Total inhospital mortality was 2.9%, and 24.4% of patients experienced at least one major complication during their hospital stay. Intrathecal morphine was associated with a lower risk of postoperative morbidity (OR 0.51, 95% CI 0.28 - 0.89), particularly pulmonary complications (OR 0.54, 95% CI 0.31 - 0.93) and renal dysfunction (OR 0.52, 95% CI 0.29 - 0.97). Other predictors of nonsurgical complications were ASA physical status 3 and 4 (OR 1.94, 95% CI 1.07 - 3.52), preoperative renal dysfunction (OR 1.61, 95% CI 1.01 - 2.58), prolonged surgical time (OR 1.78, 95% CI 1.16 - 2.78), and the need for blood transfusion (OR 1.77, 95% CI 1.05 - 2.99). CONCLUSIONS This single-center study showed a decreased risk of major nonsurgical complications in patients who received neuraxial analgesia after abdominal aortic surgery.

No association between ultrasound-guided insertion of central venous catheters and bloodstream infection: a prospective observational study

BACKGROUND Ultrasound guidance for the insertion of central venous catheters (CVCs) reduces mechanical complications and shortens insertion time, but its effect on CVC-associated bloodstream infection (CABSI) remains controversial. AIM To test the effect of ultrasound-guided CVC insertion on CABSI in a hospital-wide setting. METHODS A four-year prospective cohort study was conducted at a university-affiliated, tertiary care centre. All patients receiving a non-tunnelled CVC, inserted by an anaesthetist, were enrolled. Catheter surveillance was performed by trained infection control nurses and checked by an infection control doctor. The primary outcome was CABSI as defined by the US Centers for Disease Control and Prevention. The secondary outcome was all-cause mortality up to 28 days after CVC removal. FINDINGS In total, 2312 patients with 2483 CVCs were included and analysed. Ultrasound guidance was used for 844 CVC insertions (34.0%), with a significant increasing trend over the study period [incidence rate ratio 1.13, 95% confidence interval (CI) 01.11-1.15; P < 0.001]. Forty-seven CABSIs were identified, representing an overall incidence of 2.1 episodes per 1000 catheter-days. No association was detected between ultrasound guidance and CABSI (hazard ratio 0.69, 95% CI 0.36-1.30; P = 0.252). All-cause mortality was 11.0% (253/2312), with no significant trend and no association with ultrasound guidance. CONCLUSION Ultrasound guidance had no effect on CABSI or mortality. In a hospital-wide setting with baseline CABSI rates at the standard level currently found in high-income countries, the use of ultrasound has no additional benefit for the prevention of CABSI.

Simulation-based medical education training improves short and long-term competency in, and knowledge of central venous catheter insertion: A before and after intervention study.

BACKGROUND Multimodal educational interventions have been shown to improve short-term competency in, and knowledge of central venous catheter (CVC) insertion. OBJECTIVE To evaluate the effectiveness of simulation-based medical education training in improving short and long-term competency in, and knowledge of CVC insertion. DESIGN Before and after intervention study. SETTING University Geneva Hospital, Geneva, Switzerland, between May 2008 and January 2012. PARTICIPANTS Residents in anaesthesiology aware of the Seldinger technique for vascular puncture. INTERVENTION Participants attended a half-day course on CVC insertion. Learning objectives included work organization, aseptic technique and prevention of CVC complications. CVC insertion competency was tested pretraining, posttraining and then more than 2 years after training (sustainability phase). MAIN OUTCOME MEASURES The primary study outcome was competency as measured by a global rating scale of technical skills, a hand hygiene compliance score and a checklist compliance score. Secondary outcome was knowledge as measured by a standardised pretraining and posttraining multiple-choice questionnaire. Statistical analyses were performed using paired Students t test or Wilcoxon signed-rank test. RESULTS Thirty-seven residents were included; 18 were tested in the sustainability phase (on average 34 months after training). The average global rating of skills was 23.4 points (±SD 4.08) before training, 32.2 (±4.51) after training (P < 0.001 for comparison with pretraining scores) and 26.5 (±5.34) in the sustainability phase (P = 0.040 for comparison with pretraining scores). The average hand hygiene compliance score was 2.8 (±1.0) points before training, 5.0 (±1.04) after training (P < 0.001 for comparison with pretraining scores) and 3.7 (±1.75) in the sustainability phase (P = 0.038 for comparison with pretraining scores). The average checklist compliance was 14.9 points (±2.3) before training, 19.9 (±1.06) after training (P < 0.001 for comparison with pretraining scores) and 17.4 (±1.41) (P = 0.002 for comparison with pretraining scores). The percentage of correct answers in the multiple-choice questionnaire increased from 76.0% (±7.9) before training to 87.7% (±4.4) after training (P < 0.001). CONCLUSION Simulation-based medical education training was effective in improving short and long-term competency in, and knowledge of CVC insertion.