Central-line-associated bloodstream infections (CLABSIs) occur during the insertion or change of the dressing of the central venous catheter (CVC) and are reportable healthcare-associated infections at the state and the national level. The purpose of this systematic review of the literature was to evaluate and synthesize available evidence to establish the effectiveness of using an adhesive transparent chlorohexidine gluconate (CHG) Tegaderm™ gel dressing for CVC in the prevention of CLABSIs. The logic model was used as a framework to guide the review of the literature to establish how an intervention that is not currently practiced can contribute to CVC prevention of infection. The practice question focused on gathering evidence to support the effects of CHG Tegaderm™ gel central-line dressing compared with the Biopatch® dressing. A total of 373 articles were retrieved and 16 met the inclusion for review and were graded according to the Melnyk and Fineout-Overholt hierarchy level of evidence and evidence synthesis broken down into the reduction of CLABSI, the cost-effectiveness and ease of use of the CHG Tegaderm™ gel. Findings from the systematic review supported the use of CHG gel dressing as a CLABSI preventative measure. The findings from the project support positive social change by reducing CLABSI and associated illnesses and saving the increased cost, mortality, and morbidity associated with CLABSIs.

The Relationship Between Central Venous Catheter and Post-operative Complications in Patients Undergoing Hepatic Resection David C. O’Connor, Ph.D., DNAP, CRNA A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University Virginia Commonwealth University, 2018 Dissertation Chair: Clarence J. Biddle, Ph.D., CRNA Hepatic resection is indicated for primary and secondary malignancies. Use of a low central venous pressure technique is associated with decreased blood loss in these cases. This technique has evolved; central venous catheters and high dose morphine are no longer used, and patients are extubated earlier. The purpose of this study is to assess a relationship between these changes and outcomes. Central venous pressure has fallen out of favor as an accurate fluid measurement. Central venous catheters are associated with many complications. Outcomes in patients undergoing hepatic resection have improved over 20 years at one high volume institution. Guided by Donabedian’s theory of measuring outcomes, a non-randomized, non-experimental, retrospective, cohort design was conducted. The independent variables were intraoperative insertion of a central venous catheter, use of morphine, and time of extubation. The dependent variables were superficial and deep wound infections, number and severity of complications. The population sample is patients who submitted to partial hepatectomy at Memorial Sloan Kettering Cancer Center from 2007-2016. Data was obtained from hepatobiliary and anesthesia databases at Memorial Sloan Kettering Cancer Center. Data of 2518 from a possible 3903 patients were analyzed with chi square, univariate, Poisson and multivariate regressions. Univariate analysis for presence of CVC was significant for 90-day mortality (p 0.013). Use of morphine was significant for superficial wound infection (p 0.035), and a decrease in complications (p <.001). Amount of morphine was associated with fewer severe complications (p <.001). Incidental findings included a relationship between gender, total amount of fluids and number of segments resected. The significance of CVC with 90-day mortality was eliminated with stepwise multivariate regression. The findings support the change in anesthetic practice with clinical significance. Incidental findings regarding fluids and segments are supported in the literature. Future research should include goal directed fluid therapy and investigation of the relationship between gender and outcomes.

This study addressed an increasing number of peripheral intravenous catheter infiltrations within hospitals, leading to problems such as phlebitis and cellulitis, which may result in a longer length of hospital stay. The purpose of this project was to determine how to reduce infiltrations in order to increase the longevity of the catheter. A quantitative, description design was used, guided by Abdellah's classification framework for identifying nursing problems. The target population was 50 patients experiencing incidents of peripheral intravenous catheter infiltration, identified in a patient safety event log used across a 252-bed hospital. Each incident was assessed for several risk factors, such as age, diagnosis, length of time of catheter use, co-morbidities, size of catheter used for insertion, and how many medications were being administrated intravenously. Using descriptive statistics, the combination of patient co-morbidities had a direct correlation with increased probability of infiltration before 96 hours. Among 82% of patients, co-morbidities included hypertension in 56% of subjects, advancing age, and placement of the catheter in the upper arm. Data play a significant role in decisions to change clinical practice and protocols. Findings from this study related to peripheral intravenous catheter insertions, and their maintenance can drive changes across a healthcare organization.

Chronic kidney disease (CKD) is preventable and reversible in the early stages with upstream strategies; however, the number of individuals diagnosed with end-stage renal disease (ESRD) is increasing annually. Although researchers have documented the physiological and psychological stressors associated with hemodialysis (HD), little is known about the effects of in-center HD on the recipients in DeKalb County, Georgia. This study described the experiences of 10 African American HD patients who dialyze in DeKalb County. Using a phenomenological approach, the interviews were transcribed and then analyzed for significant quotes and recurrent themes relevant to receiving HD in DeKalb County. The health belief model was used to identify the perceptions and susceptibilities that formed the lived experiences of the participants. Results showed that 70% of the patients had been diagnosed with hypertension and/or diabetes and that 50% had never heard of ESRD prior to diagnosis. All 10 patients reported never knowing that hypertension and/or diabetes was a major cause of ESRD. The study sought to find common themes related to the perceived threat of ESRD by the participants. This study can be used to implement positive social change by instituting upstream strategies to decrease the prevalence of ESRD or slow the progression of CKD in this population, heightening awareness of this disease in minority communities, and implementing a sustainable health behavior plan to decrease the prevalence of the disease.

Introduction: Radiofrequency ablation (RFA) is a popular method of treating unresectable liver tumours by the use of a high frequency, alternating electrical current that heats and destroys tumour cells. The size of the ablation is limited by localised charring of adjacent tissue that prevents further conduction of the radiofrequency current. In the clinical setting, this results in increased rates of local recurrence in tumours that are greater than 3 cm in diameter as multiple, overlapping ablations need to be performed to treat the one tumour. To overcome this problem, a modified form of RFA called Bimodal Electric Tissue Ablation (BETA) has been created. BETA adds a direct electrical current to the alternating radiofrequency current, thus establishing its bimodal character. When direct currents are used in biological tissues, water is transferred from anode to cathode by a process called electro-osmosis. By attaching the cathode to the radiofrequency electrode, water is attracted to the area thus preventing tissue desiccation and charring. The BETA circuit has been constructed and tested using a porcine model. The aims of the studies are to confirm that larger ablations can be produced with the BETA system and that it is safe to use in an animal model. Three studies have been performed to test these aims in porcine liver. Methods: The first study was designed to compare sizes of the ablation produced between standard RFA and the BETA circuit. This was followed by a long-term study to assess associated changes to liver function and pathological changes within the liver as well as identifying any other treatment related morbidity. The third study assessed the difference in ablation size and safety aspects when the positive electrode of the direct current circuitry was moved from small surface area under the skin to a large surface area on the skin. Results: Ablations with significantly larger diameters are created with the BETA circuit using a multi-tine needle (49.55 mm versus 27.78 mm, p<0.001). This finding was confirmed in the third experiment using a straight needle (25 mm versus 15.33 mm, p<0.001). Ablations produced by the BETA circuit induce coagulative necrosis within the treated liver and the injury heals by fibrosis in a manner similar to other thermal therapies. Significant rises in some serum liver enzymes are seen within 24 hours of treatment but these return to normal within 4 days. An electrolytic type injury can be produced at the site of the positive electrode. By increasing the surface area of this electrode, the risk of tissue damage is decreased but ablations are significantly smaller (18 mm versus 25 mm, p<0.001). Conclusions: The BETA circuit consistently produces significantly larger ablations than RFA. The treatment appears safe but positioning of the positive electrode of the direct current requires careful consideration. Injuries produced behave like other thermal therapies with coagulative necrosis followed by fibrotic healing. As larger ablations are consistently produced, it is hypothesised that with further refinements, tumours greater than 3 cm in diameter could be treated with lower rates of recurrence. / Thesis (M.S.) -- University of Adelaide, School of Medicine, 2008

Introduction: Haemodialysis (HD) is a treatment in which blood from the patient is lead through a tubing system into a dialysis device in a extracorporeal circuit. This circuit contains semipermeable membranes (dialyzer). Blood with uraemic toxins flows on one side, and a salt solution flows on the other side. The salt solution flushes away waste products that have passed the membrane by diffusion or convection through small pores. From there the blood returns to the patient through a tubing system that contains an air-trap and a sensor to avoid air contamination in the blood. Besides air contamination, this treatment is burdened with safety problems such as biocompatibility, electrical safety and mechanical safety. The aim of this thesis was to investigate the safety issues in haemodialysis devices regarding leakage current and air contamination during standard procedures and simulated fault conditions. Does the dialysis device constitute a risk for the patient? Methods: To determine the extent of leakage current in HD machines, measurements at the filter-coupling site were performed in vitro according to the safety standard, IEC 601-1, in 5 types of dialysis machines. To determine, in vitro, to what extent blood and priming fluid allowed leakage current to pass to the patient, leakage current were also measured in the blood lines. The blood line was filled with blood from donors or priming fluid in eight different runs. To determine if leakage current could influence biocompatibility, a Fresenius 2008C dialysis machine and 8 hemophan dialyzers were used. Blood lines contained about 400 ml heparinized blood from each of 8 different donors (in vitro). C3d was measured, in vitro, before start of a simulated dialysis and at 15, 30, 45 and 60 min. during standard dialysis procedure. Then 1.5 mA current was switched on and additional samples were drawn at 75 and 90 min. Some patients need a central dialysis catheter (CDC) for access, placed close to or within the heart. To analyze if leakage current during standard HD would influence the ECG, patients with CDC or with AV-fistula as access were investigated. To analyse if air contamination could occur without activating security alarms in the dialysis device, various modes of in vitro dialysis settings were studied, some using a dextran solution to mimic blood viscosity. Besides visual inspection an ultrasound detector for microemboli and microbubbles was also used. Results: The data showed leakage current at the filter coupling site that was significantly higher for some devices than for others. The leakage current could pass through blood and priming fluid. It exceeded the cardiac floating (CF)-safety limit (&lt;50μA) at the top of the CDC using the test mains on applied part for saline (median 1008μA), for blood (median 610μA) and for a single fault condition using saline (median 68 μA) or blood (47 μA). The leakage current experiments showed that complement activation worsened as the leakage current increased. During standard dialysis arrhythmia could occur. Microbubbles were visible at the bottom of the air-trap and bubbles could pass the air-trap towards the venous line without triggering the alarm. During recirculation, several ml of air could be collected in an intermediate bag after the venous line. Ultrasound showed the presence of bubbles of sizes 2.5-50 μm as well as more than 50 μm silently passing to the venous line in all runs performed. In conclusion, the data showed that a leakage current in HD devices can be high enough to be a safety risk for the patient. This risk is greater if a single fault arises in the dialysis machine or another device connected to the same patient, or during mains contact to the patient. Then the current flow may be high enough to cause arrhythmia for the patient, especially when using a CDC. There is also reason for concern that micro bubble transmission may occur without inducing an alarm. These factors need to be looked over to improve safety regulations and optimize HD treatment and service schedules.

No description available.

A peripherally inserted central catheter (PICC line) is a catheter that is inserted through a peripheral vein in the arm and then on to a central vein in the chest. It is used to give injections and infusions and to take blood samples of patients who need treatment for longer periods.The aim of this study was to investigate nurses' perceived knowledge of the care and use of PICC line in wards where PICC line does not occur daily. The aim was also to investigate if the nurses expressed a need and wished for more knowledge to be able to use PICC line, and if PICC line is not used investigate the cause of that.The study was of a descriptive design with quantitative approach. An online survey was answered by 40 nurses from five wards at a university hospital in central Sweden.A large number of the nurses who responded to the survey reported that they lacked knowledge of the care and use of PICC line. Despite this, three-quarters of the nurses usually use PICC line at the infusion / injection / blood tests on patients with PICC line, if they are cared for in their ward. Most of the nurses wanted more knowledge on PICC line and the majority of them wanted to get this knowledge through education in the ward. Nearly one-third of the nurses had not received any training on PICC line.The conclusion is that nurses who often care for patients with PICC line largely lack knowledge about the use and care of PICC line. Despite this, most nurses use PICC line if they are caring for a patient who has one. To avoid complications in patients with PICC line nurses need to get more training on the use and care of these. Most nurses want more training and knowledge of PICC line. / En perifert inlagd central venkateter (PICC-line) är en kateter som läggs in via en perifer ven i armen och sedan vidare till en central ven i bröstkorgen. Den används för att ge injektioner och infusioner och för att ta blodprover på patienter som behöver en längre tids behandling.Syftet med denna studie var att undersöka sjuksköterskors uppfattade kunskap om skötsel och användning av PICC-line på vårdavdelningar där PICC-line inte förekommer dagligen. Syftet var också att undersöka om sjuksköterskorna tyckte sig behöva och önskade mer kunskap för att kunna använda PICC-line och i de fall den inte används undersöka orsaken till det.Studien var av deskriptiv design med kvantitativ ansats. En webbenkät besvarades av 40 sjuksköterskor från fem vårdavdelningar vid ett universitetssjukhus i Mellansverige.En stor del av de sjuksköterskor som besvarat enkäten uppgav att de saknade kunskap om skötsel och användning av PICC-line. Trots detta använder tre fjärdedelar av sjuksköterskorna oftast PICC-line vid infusion/injektion/blodprovstagning om patienter med PICC-line vårdas på deras avdelning. De flesta sjuksköterskorna ville ha mer kunskap om PICC-line och majoriteten av dem ville få den kunskapen genom utbildning på avdelningen. Nästan en tredjedel av sjuksköterskorna hade inte fått någon utbildning om PICC-line.Slutsatsen är att sjuksköterskor som sällan vårdar patienter med PICC-line i hög grad saknar kunskap om användning och skötsel av PICC-line. Trots detta använder de flesta PICC-line om de vårdar en patient som har en sådan. För att undvika komplikationer hos patienter med PICC-line behöver sjuksköterskorna få mer utbildning om användning och skötsel av dessa. De flesta sjuksköterskorna önskar få mer utbildning och kunskap om PICC-line.

BACKGROUND: Malignant and paramalignant pleural effusions are important complications of many malignancies. The two main management options debated in the literature are: 1) insertion of an indwelling pleural catheter (IPC) to achieve chronic drainage of the effusion, or 2) hospitalization with tube thoracostomy and subsequent chemical pleurodesis (CP) with talc or doxycycline to prevent fluid reaccumulation. We aimed to describe a large series of patients with malignant pleural effusions managed with an IPC, identify and validate factors identified in the literature as predictors of spontaneous pleurodesis in the IPC group and compare the group managed with IPC to patients managed with CP. METHODS: We designed a retrospective cohort study comparing patients with malignant and paramalignant pleural effusions managed either with CP between March 1, 2003 and February 28, 2006 or IPC insertion between May 1, 2006 and April 1, 2009. The CP group was identified through the prescription of talc or doxycycline and the IPC group from the IPC clinic database. Data were collected from paper and electronic records and from the Government of Ontario. RESULTS: We identified 193 consecutive patients with an ECOG performance status of less than 4 (ECOG less than 4 means that the patient is not completely disabled and confined to bed or chair) having undergone IPC insertion and 168 who were managed with CP. None of the variables we tested were significant predictors of spontaneous pleurodesis in the IPC group. Pleural effusion control rates at 6 months were higher in the IPC group than in the CP group (52.7% vs 34.0%, p<0.01) but the rate of freedom from pleural effusion at 180 days and catheter removal at 90 days was not significantly different (25.8% in the IPC group and 34.0% in the CP group p=0.14). Patients in the IPC group had a significantly longer median survival (148 days measured from the date of catheter insertion vs 133 days in the CP group, log-rank p<0.05). CONCLUSION: We found an intriguing possible survival benefit favouring management of malignant or paramalignant effusions with an IPC. Given possible biases due to the design of this study and uncertain explanatory mechanism, this needs to be confirmed in a randomized controlled trial. Quality of life, an important measure of success for these palliative procedures, should also be measured.

No description available.