O uso de dispositivos para infusões intravasculares representa um desafio, principalmente, pela possibilidade da dispersão microbiana do local de inserção até a ponta do cateter. O procedimento de desinfecção poderá reduzir a colonização no sítio de inserção desses dispositivos, entretanto instiga uma série de questionamentos acerca da possibilidade de dispersão para o interior do lúmen, espectro de ação do antimicrobiano, e a técnica do procedimento de desinfecção. O objetivo deste estudo foi avaliar in vitro o procedimento de desinfecção das dânulas/torneiras de três vias contaminadas propositalmente com Staphylococcus aureus e Pseudomonas aeruginosa, bem como a dispersão de soluções para o interior dos lúmens. Trata-se de um experimento laboratorial in vitro, controlado e desenvolvido em duas etapas: avaliação da dispersão bacteriana por meio da contaminação intencional com cepas padrão: S. aureus (ATCC 25923) e P. aeruginosa (ATCC 27853), e a dispersão de líquidos para o interior do conector por meio do corante cristal violeta a 1%, após a fricção com solução fisiológica ou álcool etílico a 70%, visando simular o processo de desinfecção. Todos os experimentos foram realizados em triplicata por três pesquisadores distintos. A fricção dos conectores com solução fisiológica demonstrou crescimento bacteriano (P. aeruginosa e S. aureus) no interior de 41,7% dos lúmens, no entanto não houve crescimento bacteriano nas amostras após a desinfecção com solução alcoólica a 70% (p<0,001). Com relação aos percentuais das ausências de dispersão de soluções para o interior dos lúmens das dânulas, observou-se que a fricção com as soluções fisiológica e alcoólica foram de 81,5% e 66,7%, respectivamente (p=0,079). Assim, a ausência do crescimento bacteriano no lúmen das dânulas após a fricção com solução alcoólica a 70% está associada a uma série de variáveis controladas as quais remetem a preocupação, principalmente, na possibilidade de dispersão de soluções desinfetantes para o seu interior. Nesse sentido, infere-se sobre os riscos que ameaçam a segurança das pessoas submetidas a infusões intravenosas, especialmente, no que concerne a execução do procedimento de desinfecção das dânulas / The use of intravascular infusion devices presents a challenge, mainly, due to the possibility of microbial dispersion of insertion site up to catheter tip. Disinfection procedure can reduce colonization at insertion site of these devices, but it instigates a series of questions about the possibility of dispersion into the lumen, antimicrobial action spectrum, and the technique of the disinfection procedure. The objective of this study was to evaluate in vitro disinfection procedure of three-way taps purposely contaminated with Staphylococcus aureus and Pseudomonas aeruginosa as well as the dispersion of solutions into the lumens. This is an in vitro laboratory experiment, it was controlled and developed in two steps: evaluation of bacterial dispersion by intentional contamination with standard strains: S. aureus (ATCC 25923) and P. aeruginosa (ATCC 27853), and liquid dispersion into the connector through 1% violet crystal dye, after friction with physiological solution or 70% ethyl alcohol, in order to simulate disinfection process. All experiments were performed in triplicate by three distinct researchers. The friction of connectors with physiological solution showed bacterial growth (P. aeruginosa and S. aureus) within 41.7% of the lumens, but there was no bacterial growth in the samples after disinfection with 70% alcoholic solution (p<0.001). Regarding the absence of dispersion percentages of solutions into the lumens from three-way taps, it was observed that the friction with physiological and alcoholic solutions were 81.5% and 66.7%, respectively (p=0.079). Thus, the absence of bacterial growth in the lumen from three-way taps after the friction with 70% alcoholic solution is associated to a series of controlled variables which refer, mainly, to the possibility of dispersion of disinfectant solutions to its interior. In that sense, it is inferred about risks that threaten the safety of people undergoing intravenous infusion, especially, concerning the disinfecting procedure execution for three-way taps

A manutenção do cateter venoso periférico (CVP) é um tema complexo que exige o cumprimento de uma série de conformidades na prevenção e controle dos eventos adversos, como a flebite. Neste estudo avaliou-se a microbiota e o perfil de sensibilidade aos antibióticos das bactérias isoladas em curativos e dânulas utilizados na manutenção do CVP. Assim, relacionou-se o tempo de permanência do acesso e a presença ou não de sujidade com o crescimento bacteriano em meios de culturas seletivos e a ocorrência de cepas multidroga resistentes (MDR). Trata-se de um estudo observacional de prevalência realizado com pacientes adultos hospitalizados em terapia intravenosa periférica. Nesse sentido, a coleta envolveu 30 dânulas (30 amostras do seu lúmen e 30 da sua superfície externa) e 30 curativos totalizando-se 90 análises microbiológicas. No processamento microbiológico do curativo utilizou-se suabe friccionado em área previamente demarcada e para o lúmen realizou-se flush nas duas vias da dânula. Todas as amostras foram semeadas em meio TSB (Tryptic Soy Broth) e a incubação procedeu-se a 37°C por 24hs até 14 dias. Os meios de cultura seletivos utilizados foram Manitol Salgado, MacConkey e Cetrimide. Na Identificação das cepas e do antibiograma utilizou-se o procedimento automatizado VITEK®. Os testes: exato de Fischer, não paramétrico de Mann-Whitney e Qui-Quadrado de Pearson subsidiaram a análise estatística com nível de significância de 5% (? = 0,05). O estudo teve aprovação do Comitê de Ética em Pesquisa. Diante da variabilidade dos resultados é importante destacar que 100% das superfícies externas das dânulas, 40% dos lúmens e 86,7% dos curativos apresentaram crescimento bacteriano. E, com relação às espécies isoladas no lúmen destacam-se: 50% Staphylococcus coagulase-negativo, 14,3% Staphylococcus aureus, 14,3% Pseudomonas aeruginosa, 7,1% Klebsiella pneumoniae e 7,1% Proteus mirabilis. Em relação ao perfil de sensibilidade identificaram-se bactérias MDR em 59% das superfícies externas das dânulas, 44% nos curativos e 42% nos lúmens, com predomínio de Staphylococcus coagulase-negativo resistente ao antibiótico oxacilina. Bactérias Gram-negativas com resistência a carbapenêmicos foram isoladas nas superfícies externas das dânulas, sendo 9% Klebsiella pneumoniae, 4,5% Pseudomonas aeruginosa e 4,5% Acinetobacter baumannii. Evidenciou-se associação entre o crescimento bacteriano em meio TSB e a presença de sujidade (p=0,014). A comparação entre a média dos dias de CVP e o crescimento bacteriano no meio MacConkey apresentou diferença significativa (p=0,018). No geral, os resultados preocupam considerando, principalmente, o crescimento bacteriano no lúmen das dânulas. Outras investigações são promissoras para que se possa de fato ampliar as evidências acerca das condições microbiológicas na manutenção desse acesso venoso, estabelecer relações com as variáveis clínicas e, assim subsidiar os protocolos de assistência na prevenção e controle dos riscos de infecção. / The maintenance of the peripheral venous catheter it´s a complex theme that requires the accomplishment of some compliances at the control and prevention of adverse events, such as phlebitis. This study evaluated the microbiota and the sensitivity test to antibiotics at bacteria isolated from dressing and connector used on the maintenance of the peripheral venous catheter. Therefore, it was related the residence time of the access and the presence or absence of dirtiness with the bacterial growth on selective culture media and the occurrence of multidrug resistance strains. It´s about an observational study realized with adults patients hospitalized in use of peripheral intravenous therapy. The collect involved 30 connector (30 samples of the lumen and 30 samples of the external surface) and 30 dressing in a total of 90 microbiological analyzes. At the microbiological processing of the dressings it was rubbed swabs at a previous demarcated area and for the lumen it was used a flush at the two parts of the connector. All the samples were seeded on Tryptic Broth Soy (TBS) and the incubation was carried out at 37ºC for 24 hours on 14 days. The selective culture media used were Mannitol, MacConkey and Cetrimide. For the strain identification and the antibiogram it was used the automatic procedure VITEK®. The tests: Fisher exact test, nonparametric Mann-Whitney and Chi-square test subsidized the statistics analysis with a level of significance at 5% (? = 0,05). The study was approved at the Ethics Committee in Research. In front of the variability of the results it´s important to detach that 100% of the external surface of the connector, 40% of the lumen and 86,7% of the dressing showed bacterial growth. From the species isolated on the lumen stands out 50% of coagulase negative Staphylococcus, 50% Staphylococcus aureus, 14,3% Pseudomonas aeruginosa, 7,1% Proteus mirabilis. Acording to the sensitivity test to antibiotics it was identified multidrug resistance bacteria on 59% of the external surface of the connector, 44% of the dressing and 42% of the lumen, with a predominance of coagulase negative Staphylococcus resistant to oxacillin. Gram negative bacteria with resistance to carbapenem were isolated on the external surface of the connector, these are 9% Klebsiella pneumoniae, 4,5% Pseudomonas aeruginosa and 4,5% Acinetobacter baumannii. It was evidenced an association between bacterial growth on TSB culture media and the presence of dirtiness (p=0,014). The proportion between the medium days of peripheral venous catheterization and the bacterial growth on MacConkey media culture showed significant difference (p=0,018). In general, the results concern mostly because of the bacterial growth on the connector lumen. Others investigations are promissory to the amplification of evidence on microbiological conditions on the maintenance of the venous catheterization, establish relations with clinic variables and subsidize the assistance protocols on the control and prevention of infections risks.

<p>UVOD: Komplikacije terminalne bubrežne isuficijencije (TBI) kada se jačina glomerularne filtracije (JGF) smanji ispod 10 mL/min moguće je lečiti jedino hroničnom dijalizom ili transplantacijom bubrega tj. nadoknadom potpuno ili delimično izgubljene bubrežne funkcije. Uz blagovremenu edukaciju bolesnika o progresivnom toku hronične bubrežne bolesti, mogućnostima dijaliznog tretmana i transplantacije bubrega, treba na vreme obezbediti stalni funkcionalni vaskularni pristup za hemodijalizu (HD) hirur&scaron;kom intervencijom kreiranja arteriovenske fistule (AVF), po mogućnosti najmanje 6 meseci pre anticipiranog započinjanja HD, jer je za njenu maturaciju potrebno 4 do 6 nedelja. Primarna AVF je op&scaron;tepreporučeni najbolji stalni vaskularni pristup za bolesnike kod kojih se planira hemodijaliza. Najče&scaron;ći razlog za disfunkciju vaskularnog pristupa za hemodijalizu su u 80% slučajeva trombozne komplikacije, koje se u 90% slučajeva javljaju na venskom segmentu AVF i posledica su progresivne venske neointimalne hiperplazije. Pored histolo&scaron;kih karakteristika zida venskog krvnog suda i hemodinamskih uslova, u etiopatogenezi ovog &raquo;adaptivnog odgovora&laquo; vrlo značajnu ulogu igraju endotel i ostale komponente hemostaznog sistema (trombocitna, koagulaciona i fibrinolizna), imunolo&scaron;ki i citolo&scaron;ki činioci i genetski faktori. Prevencija nastanka rane tromboze vaskularnog pristupa za hemodijalizu kod bolesnika sa TBI je moguća primenom antitromboznih lekova, tj. antitrombocitne ili antikoagulantne terapije. CILJ: Proceniti efikasnost primenjenih antitromboznih lekova (tiklopidina i nadroparin-kalcijuma) u prevenciji nastanka rane tromboze/afunkcionalnosti AVF za hemodijalizu za vreme njene maturacije unutar 6 nedelja od kreiranja u bolesnika sa TBI. Ispitati nivo biomarkera hemostaznog sistema i markere trombofilije u bolesnika sa TBI pre kreiranja AVF u cilju dopune uzroka nastanka rane tromboze/afunkcionalnosti arteriovenskih fistula za hemodijalizu. Ispitati učestalost trombofilije i njen uticaj na funkcionalnost AVF i uporediti efikasnost primenjenih preventivnih režima između bolesnika sa i bez trombofilije. MATERIJAL I METODE: U ispitivanje su uključene osobe oba pola sa prethodno postavljenom dijagnozom TBI kod kojih nisu postojale kontraindikacije za planirno hirur&scaron;ko kreiranje prvog stalnog vaskularnog pristupa za hemodijalizu u vidu autologne arteriovenske fistule (AAVF). Nakon hirur&scaron;kog kreiranja radiocefalične arteriovenske fisule u distalnoj trećini podlaktice nedominantne ruke (89/121), intermedijalne (4/121) ili proksimalne (28/121) AAVF u studiju je uključen 121 ispitanik, koji su u cilju procene uticaja različitih antitromboznih lekova na sprečavanje nastanka rane tromboze fistula za hemodijalizu kod bolesnika sa TBI ispitanici su podeljeni u 3 grupe: Grupa I, kontrolna; 40 ispitanika koji nakon kreiranja AVF nisu dobijali antitromboznu terapiju, Grupa II; 42 ispitanika kod kojih je dan nakon kreiranja AVF započeta primena antitrombocitnog leka iz grupe tienopiridina, Ticlodix&reg; (ticlopidin) tbl a 250 mg, 2 x &frac12; tbl dnevno tokom 6 nedelja i Grupa III; 39 ispitanika kod kojih je dan nakon kreiranja AVF započeta subkutana primena antikoagulantnog leka iz grupe niskomolekularnih heparina, Fraxiparine&reg; (nadroparin-kalcijum) 2850 anti Xa i.j. (0.3 ml) dnevno tokom 6 nedelja. Jednokratno određivanje laboratorijskih parametara pokazatelja bubrežne funkcije, metabolizma glukoze i hroničnog zapaljenja, funkcionalnosti hemostaznog sistema, trombofilnih markera i genskog polimorfizma vr&scaron;eno je unutar dve nedelje pre hirur&scaron;kog kreiranja AAVF. Kriterijum za utvrđivanje ishoda uticaja antitrombozne terpije predstavlja maturacija AVF koja je definisana kao uspe&scaron;na ako je započeto sprovođenje efikasne hemodijalize najranije 6 nedelja nakon njenog hirur&scaron;kog kreiranja po proceni nadležnog nefrologa. Dijagnoza prisustva tromboze AVF postavljena je od strane nadležnog vaskularnog hirurga/nefrologa fizikalnim pregledom tokom njene maturacije, koji je podrazumevao inspekciju, palpatorno utvrđivanje odsustva karakterističnog trila i auskultatornih karakteristika protočnosti AVF ili ultarsonografskim pregledom od strane radiologa. REZULTATI: Između ispitivanih grupa u odnosu na broj tromboziranih/ afunkcionalnih AVF tokom njene maturacije (12/40 vs. 4/42 vs. 5/39; P=0.033), ustanovljena je značajna statistička razlika kao i poređenjem broja tromboziranih/afunkcionalnih AVF tokom sazrevanja u kontrolnoj grupi u odnosu na grupu ispitanika (objedinjene Grupe II i Grupa III) koja je primala antitromboznu profilaksu (12/40 vs. 9/81; P=0.009). Daljom analizom ispitivanih grupa, utvrđena je statistički značajna razlika u broju tromboziranih/afunkcionih AV fistula između kontrolne Grupe I i Grupe II (P=0.019). Testiranjem razlike u broju tromboziranih/ afunkcionalnih AVF između ispitanika kontrolne Grupe I i Grupe III nije dobijena statistički značajna razlika, kao ni između Grupe II i Grupe III. Zastupljenost broja tromboziranih/afunkcionalnih distalnih AVF za vreme njihove maturacije (12/33 vs 2/31 vs. 3/24; P=0.008) se između ispitivanih grupa značajno statistički razlikovala kao i zastupljenost tromboziranih/afunkcionalnih distalnih AVF tokom sazrevanja u kontrolnoj grupi u odnosu na grupu ispitanika koja je primala antitromboznu profilaksu (12/34 vs. 5/55; P=0.002). Testiranjem statističke razlike u broju tromboziranih/afunkcionalnih distalnih AVF između ispitanika kontrolne Grupe I i Grupe II utvrđena je statistički značajna razlika (P=0.005), dok između Grupe I i Grupe III (P=0.051), kao ni između Grupe II i Grupe III (P=0.439) nije dobijena statistički značajna razlika. Između podgrupa ispitanika kod kojih je do&scaron;lo do tromboze/afunkcionalnosti AVF 21/121 (17.35%) i podgrupe ispitanika sa funkcionalno maturiranom AVF 90/121 (82.64%), značajna statistička razlika ispitanih hemostaznih parametara je bila prisutna u vrednostima agregabilnosti trombocita uz kolagen kao induktor (59.33&plusmn;33.1 vs. 75.04&plusmn;29.6; P=0.033). Značajna statistička razlika je zabeležena i u zastupljenosti sledećih trombofilnih markera: deficita PC (3/21 vs. 3/100; P=0.030), APC-R (4/21 vs. 5/100; P=0.026), prisustva antifosfolipidnih ACL IgM antitela (1/21 vs. 0/100; P=0.028), heterozigotnog polimorfizma FV G1691A (3/21 vs. 3/100; P=0.03) i homozigotne mutacije gena FII G20210A (1/21 vs. 0/100; P=0.028), između podgrupa bolesnika sa tromboziranom afunkcionalnom i funkcionalnom AVF. Takođe je značajna statistička razlika između podgrupa bolesnika kod kojih je do&scaron;lo tromboze/afunkcionalnosti AVF i podgrupe ispitanika sa funkcionalno maturiranom AVF bila prisutna u odnosu na postojanje ranijih tromboza (23/21 vs 19/100; P=0.000) kao i zastupljenosti izolovanih venskih tromboza (9/21 vs. 2/100; P=0.000). Prediktivni potencijal pojedinačnih parametara za maturaciju AVF ispitan je univarijantnom logističkom regresionom analizom. Prilikom ispitivanja uticaja pojedinačnih parametara na maturaciju fistule, zapazili smo da su ispitanici koji su primali antitromboznu terapiju imali 3 puta veću &scaron;ansu za funkcionalno maturiranu AVF [OR 3.45 (1.3-9.03)] u odnosu na bolesnike bez terapije. Ispitanici koji su imali prethodne tromboze su imali vi&scaron;estruko povi&scaron;en rizik [OR 6.92 (2.51-19.06)] za nastanak tromboze/afunkcionalnost AVF tokom maturacije. Prilikom ispitivanja uticaja pojedinačnih parametara na rizik od pojave tromboze/afunkcionalnosti distalne AVF, zapažamo da primena antitrombozne terapije [OR 5.4 (CI 1.7 - 17.35)] petostruko snižava rizik za nastanak tromboze/ afunkcionalnosti distalne AVF, odnosno da primena antitrombozne terapije petostruko povećava &scaron;ansu za adekvatnu maturaciju distalne AVF. Ispitanici koji su imali aterosklerotske KVB [OR 0.32 (0.1-0.98)] i ranije tromboze [OR 0.14 (0.04-0.44)] su imali za 68% i 86% manju verovatnoću za adekvatnu maturaciju distalne AVF (334). Trombofilija je bila prisutna u 59/121 (48.8%) ispitanika. U odnosu na markere aktivacije koagulacione komponente hemostaznog sistema i inflamatorne pokazatelje, između podgrupa ispitanika sa ili bez trombofilije statistički značajna razlika je bila prisutna u vrednostima koncentracije FVIII (170.35&plusmn;103.97 vs. 235.26&plusmn;124.80; P=0.02) i odnosa trombociti/limfociti (181&plusmn;64.58 vs. 148.11&plusmn;66.15; P=0.026). U odnosu na lokalizaciju AVF, u podgrupi ispitanika sa trombofilijom i tromboziranom/ afunkcionalnom AVF, njih 8/11 su pripadale distalnim AVF, 3/11 proksimalnim AVF, dok je u podgrupi ispitanika bez trombofilije i tromboziranom/afunkcionalnom AVF, njih 9/10 imalo distalnu, a 1/10 proksimalnu AVF. U grupi bolesnika sa trombofilijom nije zabeleženo prisustvo statistički značajne razlike u efikasnosti primenjenih antitromboznih režima merene učestalo&scaron;ću tromboza/afunkcionalnosti AVF u odnosu na bolesnike sa trombofilijom koji nisu primali antitromboznu terapiju (5/19 vs. 2/18 vs. 4/22; P=0.493). U grupi ispitanika bez trombofilije utvrđeno je postojanje statistički značajne razlike u učestalosti tromboza/afunkcionalnosti AVF između grupe sa i bez primene antitromboznih lekova kako u ukupnom broju tromboziranih/afunkcionalnih AVF (7/21 vs. 2/24 vs. 1/17; P=0.030). Iako je zastupljenost tromboza/afunkcionalnosti AVF u bolesnika sa kombinovanom trombofilijom če&scaron;ća u odnosu na ispitanike koji su imali drugu vrstu ili uop&scaron;te nisu imali trombofiliju (6/18 vs. 15/103; P=0.052), ona nije dostigla statistički značajnu vrednost. ZAKLJUČAK: Profilaktička primena antitromboznih lekova (tiklopidina i nadroparin-kalcijuma) smanjuje učestalost pojave rane tromboze i pojavu primarne nefunkcionalnosti AVF za hemodijalizu tokom njene maturacije. Primena antitrombozne terapije petostruko snižava rizik za nastanak tromboze/ afunkcionalnosti distalne AVF tokom njene maturacije. Bolesnici koji su imali prethodne tromboze imaju vi&scaron;estruko povi&scaron;en rizik za nastanak tromboze AVF tokom njene maturacije. Kod bolesnika koji su imali aterosklerotske KVB i ranije tromboze verovatnoća za adekvatnu maturaciju distalne AVF je niža za 68% , odnosno 86%. U na&scaron;em istraživanju nije utvrđeno postojanje superiornosti antikoagulantne u odnosu na antitrombocitnu profilaksu tj. oba primenjena režima su bila podjednako efikasna. U terminalnoj bubrežnoj insuficijenciji prisutan je značajan poremećaj funkcionalnosti hemostaznog sistema koji se očituje u disfunkciji endotela i poremećenoj (sniženoj) funkcionalnosti trombocita, prisustvu prokoagulantnog stanja koje se manifestuje povi&scaron;enom trombinskom aktivno&scaron;ću, povi&scaron;enom koncentracijom činilaca koagulacije i smanjenom fibrinoliznom aktivno&scaron;ću. Če&scaron;ća zastupljenost ukupnih ranijih tromboza (arterijskih i venskih), če&scaron;ća zastupljenost izolovanih venskih tromboza i učestalije prisustvo trombofilije prezentovano deficitom PC, prisustvom rezistencije na APC, prisusustvom antifosfolipidnih antikardiolipinskih antitela IgM, heterozigotnog polimorfizma FV G1691A, homozigotne mutacije FII G201210A i niža vrednost agregabilnosti trombocita uz kolagen kao induktor su markeri koji su u na&scaron;em ispitivanju signifikantno če&scaron;će zastupljeni kod ispitanika sa trombozom/ afunkcijom AVF za hemodijalizu tokom njenog sazrevanja. Trombofilija je prisutna kod 48.8% bolesnika saTBI, ali na&scaron;im ispitivanjem nije utvrđen njen uticaj na nastanak rane tromboze/afunkcionalnosti AVF izuzev u grupi bolesnika sa kombinovanom trombofilijom. Mali broj krvarećih komplikacija u na&scaron;oj studiji ukazuje na bezbednost primenjenog preventivnog režima. Na osnovu dobijenih rezultata može se preporučiti profilaktička primena tiklopidina ili nadroparin-kalcijuma u preventivnim dozama kod bolesnika sa TBI neposredno nakon kreiranja AVF. Primenu profilakse tromboznih komplikacija kod bolesnika sa novokreiranom AVF preporučujemo posebno kod bolesnika koji su imali prethodne tromboze i/ili kliničke manifestacije aterosklerotskih kardiovaskularnih bolesti.</p> / <p>INTRODUCTION: Complications in end stage renal disease (ESRD) when the glomerular filtration rate (GFR) decreases below 10mL/min can only be treated by chronic dialysis or kidney transplant ie. total or partial renal replacement therapy. With prompt education of the patient regarding the progressive course of the chronic kidney disease, possibilities of dialysis treatment and kidney transplantation, the patient should timely be granted permanent functional vascular hemodialysis (HD) access through surgical intervention by creating arteriovenous fistula (AVF), preferably at least 6 months prior to the anticipated start of HD, as period for its maturation is between 4 and 6 weeks. Primary AVF is the generally best recommended permanent vascular access for patients planned for dialysis. The most common reason for dysfunction of the vascular access for hemodialysis are thrombotic complications in 80% of the cases, 90% of which appear in the venous segment of AVF as the consequence of progressive venous neointimal hyperplasia. Beside the histological characteristics of the venous blood vessel wall and hemodynamic conditions, in the etiopathogenesis of this &ldquo;adaptive answer&rdquo;, endothel and other components of the hemostatic system (platelet, coagulation and fibrinolysis), immunological and cytological components as well as genetic factors play a very important role. Prevention of occurrence of early thrombosis of vascular access for hemodialysis in patients with ESRD is possible by treatment with antithrombotic drugs, ie. antiplatelet or anticoagulant therapy. OBJECTIVE: Estimate the efficiency of applied antithrombotic drugs (ticlopidine and nadroparincalcium) in prevention of occurrence of early thrombosis/dysfunction of AVF for hemodialysis during its time of maturation within the 6 week period. Examine the level of biomarkers of the hemostatic system and thrombophilic markers in patients with ESRD before the creation of AVF with the goal of finding additional causes of occurrence of early thrombosis/dysfunction of arteriovenous fistula for hemodialysis. Determine the incidence of thrombophilia and its impact on the functionality of AVF and compare the efficiency of applied preventive regimen between patients with and without thrombophilia. MATERIAL AND METHODS: The study included persons of both sexes with previously established diagnosis of ESRD in which there were no contraindications for the planned surgical creation of the first permanent vascular access for hemodialysis in the form of autologous arteriovenous fistula (AAVF). After the surgical creation of the radiocephalic arteriovenous fistula in the distal third of the forearm of the non-dominant hand (89/121), intermedial (4/121) or proximal (28/121) AAVF, the total number of 121 patients were included in the study and divided into three groups in order to estimate the influence of different antithrombotic drugs in prevention of early thrombosis for hemodialysis in patients with ESRD: Group I, control; 40 subjects which did not receive antithrombotic therapy after the creation of AVF, Group II; 42 subjects which started receiving an antithrombotic drug from the tienopiridine group, Ticlodix&reg; (ticlopidine) 2 x &frac12; of 250mg tbl, daily, during the period of 6 weeks, after the creation of AVF, and Group III; 39 subjects which started subcutaneously receiving a drug from the low-molecular weight herapin group, Fraxiparine&reg; (nadroparine-calcium) 2850 anti Xa i.j. (0.3 ml) daily, during the period of 6 weeks. One-time determination of laboratory parameters and renal function, glucose metabolism and chronic inflammation, hemostatic system functionality, thrombophilic markers and gene polymorphism was performed within two weeks prior to surgical creation of AAVF. The criteria for determining the outcome of the impact of antithrombotic therapy is the maturation of AVF, which is defined as successful if the implementation of effective hemodialysis started at least 6 weeks after its creation, where the effectiveness of hemodialysis is estimated by a competent nephrologist. The diagnosis of the presence of AVF thrombosis was set by a competent vascular surgeon/nephrologist through physical examination during its maturation, which included inspection, palpatory determination of absence of the characteristic thrill and auscultatory characteristics of the flow of AVF, or by ultrasonographic examination by the radiologist. RESULTS: Between the groups in terms of number of thrombosed/dysfunctional AVF during its maturation (12/40 vs. 4/42 vs. 5/39, P = 0.033), a significant statistical difference was established, as well as by comparing the number of thrombosed/dysfunctional AVF during maturation in the control group compared to the group of respondents (unified Group II and Group III) which received antithrombotic prophylaxis (12/40 vs. 9/81, P = 0.009). Through further analysis of the examined groups, a statistically significant difference was observed in the number of thrombosed/dysfunctional AV fistula between the control Group I and Group II (P = 0.019). There was no statistically significant difference noticed in the numbers of thrombosed/dysfunctional AVF between the subjects in the control Group I and Group III, as well as between Group II and Group III. Presence of the number of thrombosed/dysfunctional distal AVF during their maturation (12/33 vs 2/31 vs. 3/24, P = 0.008) between the groups statistically significantly varied, as well as the presence of the number of thrombosed/dysfunctional distal AVF during the maturation in the control group as compared to the group of subjects who received antithrombotic prophylaxis (12/34 vs. 5/55; P=0.002). By testing statistical differences in the number of thrombosed/dysfunctional distal AVF between the subjects in the control Group I and Group II a statistically significant difference (P = 0.005) was established, while there was no statistically significant difference between Group I and Group III (P = 0.051), nor between Group II and Group III (P = 0.439). Among the subgroup of patients with thrombosis/dysfunction of AVF 21/121 (17.35%) and the subgroup of subjects with functionally maturated AVF 90/121 (82.64%), a statistically significant difference of the examined hemostasis parameters was present in the values of platelet aggregation with collagen as the inducer (59.33 &plusmn; 75.04 vs. 33.1 &plusmn; 29.6; P = 0.033). A significant statistical difference was recorded in the presence of the following thrombophilic markers: deficit of PC (3/21 vs. 3/100; P = 0.030), APC-R (4/21 vs. 5/100; P = 0.026), the presence of antiphospholipid ACL IgM antibodies ( 1/21 vs. 0/100; P = 0.028), heterozygous FV G1691A polymorphism (3/21 vs. 3/100; P = 0.03) and homozygous gene mutation FII G20210A (1/21 vs. 0/100; P = 0.028), between the subgroups of patients with thrombosed/dysfunctional and functional AVF. There also was a significant statistical difference between the groups of patients which encountered thrombosis/dysfunction of AVF and subgroups of subjects with functional maturated AVF in relation to the existence of previous thrombosis (23/21 vs. 19/100; P = 0.000) and the presence of isolated venous thrombosis (9/21 vs. 2/100; P = 0.000). Predictive potential of individual parameters for AVF maturation was tested by univariate logistic regression analysis. During the examination of the influence of individual parameters on fistula maturation, we observed that subjects who received antithrombotic therapy were 3 times more likely to develop functionally maturated AVF [OR 3.45 (1.3-9.03)] as compared to subjects who did not receive any treatment. Subjects which previously had thrombosis had a multiple times increased risk [OR 6.92 (2:51 to 19:06)] of developing thrombosis/dysfunctional AVF during its maturation. When examining the influence of individual parameters on the risk of thrombosis/dysfunction of the distal AVF, we noted that the implementation of antithrombotic therapy [OR 5.4 (CI 1.7 - 17:35)] reduced risk of thrombosis/dysfunction of the distal AVF by five times, ie. that the implementation of antithrombotic therapy increases the chance for adequate distal AVF maturation by five times. The subjects that had atherosclerotic cardiovascular diseases (CVD) [OR 0.32 (0.1-0.98)] or previous thrombosis [OR 0.14 (0.04-00.44)] had a 68% or 86% less chance for adequate distal AVF maturation (334). Thrombophilia was present in 59/121 (48.8%) patients. In relation to the markers of activation of coagulation components of the hemostatic system and inflammatory markers, among subgroups of subjects with or without thrombophilia a statistically significant difference was present in the FVIII concentration (170.35 &plusmn; 103.97 vs. 235.26 &plusmn; 124.80; P = 0.02) and the platelets/lymphocytes ratio (181 &plusmn; 64.58 vs. 148.11 &plusmn; 66.15; P = 0.026). In relation to the localization of AVF, in the subgroup of subjects with thrombophilia and thrombosed/dysfunctional AVF, 8/11 of them belonged to distal AVF, 3/11 proximal AVF, while in the subgroup of subjects without thrombophilia and thrombosed/dysfunctional AVF, had 9/10 distal and 1/10 proximal AVF. In the group of subjects with thrombophilia there was no record of the presence of statistically significant differences in the efficiency of antithrombotic regimen which was measured by the frequency of thrombosis/dysfunction of AVF as compared to subjects with thrombophilia which did not receive antithrombotic therapy (5/19 vs. 2/18 vs. 4/22, P = 0.493). In the group of subjects without thrombophilia statistically significant differences were found in the frequency of thrombosis/dysfunctions of AVF among groups with and without the use of antithrombotic drugs in the total number of thrombosed/dysfunctional AVF (7/21 vs. 2/24 vs. 1/17, P = 0.030). Although the presence of thrombosis/dysfunction of AVF in patients with combined thrombophilia was more frequent compared to those who had other types of, or did not have thrombophilia (6/18 vs. 15/103; P = 0.052), it did not reach a statistically significant value. CONCLUSION: Prophylactic use of antithrombotic drugs (ticlopidine and nadroparin-calcium) reduces the incidence of early thrombosis and the occurrence of primary AVF dysfunction for hemodialysis during its maturation. Implementation of antithrombotic therapy reduced risk of thrombosis/ dysfunction of the distal AVF during its maturation by five times. Patients who have had previous thrombosis have multiple times greater risk of AVF thrombosis during its maturation. In patients who had atherosclerotic CVD or previous thrombosis, the probability for adequate maturation of distal AVF is lower by 68% or 86%. In our study there was no evidence of superiority of anticoagulant compared to antiplatelet prophylaxis ie. both regimens were equally effective. In ESRD there is significant disarrangement of hemostatic system functionality, which is reflected in endothelial dysfunction and disturbed (reduced) platelet functionality, the presence of procoagulant condition that is manifested by elevated thrombin activity, increased levels of clotting factors and reduced fibrinolytic activity. More frequent presence of total previous thrombosis (arterial and venous), higher frequency of isolated venous thrombosis and frequent presence of thrombophilia presented by the deficit of PC, the presence of resistance to APC, presence of anticardiolipin antiphospholipid antibodies IgM, heterozygous FV G1691A polymorphism, homozygous mutation FII G201210A and lower value of collagen induced platelet aggregation are the markers in our study which are significantly more frequent in patients with thrombosis/dysfunction of AVF for hemodialysis during its maturation. Thrombophilia is present in 48.8% of patients with ESRD, however our study does not determine its impact on early thrombosis/dysfunction of AVF except in the group of patients with combined thrombophilia. A small number of bleeding complications in our study points to the safety of the applied preventive regimen. Based on the obtained results, prophylactic use of ticlopidine or nadroparin-calcium in preventive doses can be recommended for patients with ESRD immediately after AVF creation. Prophylactic treatment of thrombotic complications in patients with newly created AVF is recommended especially in patients who have had previous thrombosis and/or clinical manifestations of atherosclerotic cardiovascular diseases.</p>

Introdução: O Cateter Central de Inserção Periférica (CCIP) é um dispositivo vascular central inserido através de veias periféricas que permite a infusão de soluções hiperosmolares e medicações por tempo prolongado. Complicações mecânicas e infecciosas podem ocorrer com seu uso, resultando em remoção não eletiva do cateter. Um escore de risco para remoção não eletiva do CCIP que considere conjuntamente o valor prognóstico ponderado de diversos fatores de risco representa uma ferramenta valiosa para o planejamento do cuidado de enfermagem com enfoque na prevenção ou atenuação dos fatores identificados, e consequente melhoria da qualidade da assistência. Objetivo: Elaborar um escore de risco para remoção não eletiva do cateter central de inserção periférica em neonatos. Método: Estudo de coorte com coleta prospectiva de dados realizado no período de 31 de agosto de 2010 a 30 de agosto de 2012 com 436 recém-nascidos internados em uma unidade de terapia intensiva neonatal de um hospital terciário em São Paulo submetidos à instalação de 524 CCIPs. As variáveis relacionadas às características clínicas do neonato, à técnica de inserção do cateter e à terapia intravenosa que indicou a instalação do CCIP foram analisadas quanto ao seu potencial preditivo para remoção não eletiva do CCIP através de análise bivariada, e posterior regressão logística. O escore de risco ponderado foi construído baseado na razão de chances das variáveis preditoras e sua acurácia foi avaliada através da área sob a curva ROC (Receiver Operating Characteristic). Resultados: O escore de risco foi composto pelos seguintes fatores de risco: diagnóstico de transtorno transitório do metabolismo (hipoglicemia, hiperglicemia, distúrbios do cálcio, magnésio, sódio e potássio), inserção prévia do CCIP, uso do CCIP 2.0 French de poliuretano com dupla via, infusão de múltiplas soluções endovenosas através do CCIP 1.9 French de silicone com única via, e posição não central da ponta do CCIP. Sua acurácia foi de 0,76 [IC 95%: 0,73-0,78]. Sua aplicação permitiu classificar os recém-nascidos em três categorias de risco: baixo (0 a 3 pontos), moderado (4 a 8 pontos) e alto ( 9 pontos) risco para remoção não eletiva. Conclusão: Recomenda-se a adoção de estratégias preventivas da remoção não eletiva do CCIP baseadas em evidência de acordo com a classificação e fatores de risco do recém-nascido. Além disso, sugere-se evitar a inserção de múltiplos cateteres, a posição não central da ponta do CCIP, e a instalação de cateteres de silicone de única via para a administração de cinco ou mais classes de soluções endovenosas. / Background: Peripherally Inserted Central Catheter (PICC) is a central vascular access device inserted via cannulation of a peripheral vein that allows the infusion of hyperosmolar solutions and medications over a prolonged dwell time. Mechanical and infectious complications can result from its use leading to nonelective removal of the device. A risk score for nonelective removal of PICC-lines that considers jointly a weighted prognostic value of several risk factors can represent a valuable tool for planning the nursing care focused on preventing or modifying identified risk factors, and thereby improving the quality of care. Aim: To develop a risk score for nonelective removal of PICCs in infants. Methods: A cohort study with prospective data collection between August 31, 2010 and August 30, 2012 in 436 infants admitted to a tertiary-level neonatal intensive care unit in São Paulo and submitted to 524PICC insertions. Variables related to the clinical characteristics of the neonate, the technique of catheter insertion, and intravenous therapy that indicated PICC were analysed for their nonelective predictive potential through bivariate analysis, followed by a logistic regression. Predictors were weighted points proportional to their odds ratio in order to develop the risk score. The accuracy of the risk score model was examined by calculating the area under the receiver operating curve (AUC). Results: The risk score was composed of the following risk factors: diagnose of transitory metabolic disorders (hyperglycaemia, hypoglycaemia, disorders of calcium, magnesium, sodium or potassium), previous PICC line insertion, insertion of 2.0 French dual-lumen polyurethane PICC, noncentral tip position, and multiple intravenous solutions in a 1.9 French single-lumen silicone PICC. The accuracy of the risk score was of AUC=0.76 [IC 95%: 0.73-0.78]. Its application allowed classify newborns into three nonelective removal risk categories: a low-risk group (0-3 points), a moderate-risk group (4-8 points), and a high-risk group ( 9 points). Conclusion: It is recommended the adoption of evidence-based preventive measures according to the classification and risk factors of the newborn in order to avoid nonelective removal of PICC. The avoidance of repeated PICC insertions, noncentral tip position, and placement of single-lumen silicone PICCs for administration of five or more intravenous solutions is suggested.

Os shunts vasculares temporários (SVT) são utilizados como uma técnica eficaz para reestabelecer rapidamente o fluxo sanguíneo em casos de lesão vascular com isquemia do membro ou órgão acometido, no qual a revascularização deverá ser postergada. Habitualmente, o SVT é inserido dentro dos cotos proximal e distal do vaso lesado através de uma abertura na pele, visando restaurar a perfusão e interromper a isquemia. O objetivo deste estudo é comparar a pressão arterial média (PAM em mmHg) e o fluxo sanguíneo (em ml/min) em dois modelos de SVT, um habitual e outro implantado por punção, bem como o tempo para a inserção destes dispositivos e suas patências primária e secundária. Realizamos experimentos em 30 suínos, somando 60 intervenções de revascularização arterial temporária dos membros posteriores: trinta SVT habituais e trinta por punção. Analisamos a PAM durante os procedimentos nos membros posteriores e o fluxo através dos dois tipos de SVT. A análise de fluxo mostrou uma diferença significativa entre os SVT testados (p=0,001), sendo menor no grupo SVT por punção. No entanto, o tempo decorrido (min) para inserção do SVT habitual foi maior do que o tempo para inserção do SVT por punção (15,32 ± 3,08 vs. 10,37 ± 1,7, p=0,001). Além disso, observamos uma recuperação da PAM nos membros submetidos aos dois tipos de SVT próxima à PAM sistêmica em 100% dos experimentos. Os resultados revelaram patência primária, secundária, e taxa de complicações similares entre os dois tipos de SVT. Concluímos que o fluxo foi menor no SVT por punção, mas a recuperação da PAM foi semelhante e com menor tempo de inserção do SVT por punção / Temporary vascular shunts (TVS) are used as an effective technique to rapidly restore blood flow in cases of vascular injury with ischemia of the affected limb or organ, in which revascularization shall be postponed. Usually, TVS is positioned within the proximal and distal stumps of the injured vessel, through an opening of the skin, in order to restore perfusion and stop the ischemia. We sought to compare mean blood pressure (MBP in mmHg) and blood flow (ml/min) between two types of TVS, a standard one and a puncture one, as well as the time spent to insert these devices. We performed an experimental study on 30 pigs, including 60 vascular interventions in posterior limbs: thirty standard TVS and thirty puncture TVS. MBP was analyzed during the interventions in both posterior limbs and the flow through both types of TVS. Flow analysis revealed a significant difference between the two types of TVS (p=0,001), being lower in the puncture TVS. However, the time spent during standard TVS insertion was greater than that of the puncture shunt (15,32 ± 3,08 min vs.10,37 ± 1,7 min, p=0,001). In addition, we observed a limb MBP recovery close to systemic MBP in 100% of the experiments. The results show similar primary and secondary patency and complication rate in both TVS types. Therefore, we conclude that the flow was lower in the puncture TVS, but the MBP recovery was similar and it took less time to be inserted

Introdução: O Cateter Central de Inserção Periférica (CCIP) é um dispositivo vascular central inserido através de veias periféricas que permite a infusão de soluções hiperosmolares e medicações por tempo prolongado. Complicações mecânicas e infecciosas podem ocorrer com seu uso, resultando em remoção não eletiva do cateter. Um escore de risco para remoção não eletiva do CCIP que considere conjuntamente o valor prognóstico ponderado de diversos fatores de risco representa uma ferramenta valiosa para o planejamento do cuidado de enfermagem com enfoque na prevenção ou atenuação dos fatores identificados, e consequente melhoria da qualidade da assistência. Objetivo: Elaborar um escore de risco para remoção não eletiva do cateter central de inserção periférica em neonatos. Método: Estudo de coorte com coleta prospectiva de dados realizado no período de 31 de agosto de 2010 a 30 de agosto de 2012 com 436 recém-nascidos internados em uma unidade de terapia intensiva neonatal de um hospital terciário em São Paulo submetidos à instalação de 524 CCIPs. As variáveis relacionadas às características clínicas do neonato, à técnica de inserção do cateter e à terapia intravenosa que indicou a instalação do CCIP foram analisadas quanto ao seu potencial preditivo para remoção não eletiva do CCIP através de análise bivariada, e posterior regressão logística. O escore de risco ponderado foi construído baseado na razão de chances das variáveis preditoras e sua acurácia foi avaliada através da área sob a curva ROC (Receiver Operating Characteristic). Resultados: O escore de risco foi composto pelos seguintes fatores de risco: diagnóstico de transtorno transitório do metabolismo (hipoglicemia, hiperglicemia, distúrbios do cálcio, magnésio, sódio e potássio), inserção prévia do CCIP, uso do CCIP 2.0 French de poliuretano com dupla via, infusão de múltiplas soluções endovenosas através do CCIP 1.9 French de silicone com única via, e posição não central da ponta do CCIP. Sua acurácia foi de 0,76 [IC 95%: 0,73-0,78]. Sua aplicação permitiu classificar os recém-nascidos em três categorias de risco: baixo (0 a 3 pontos), moderado (4 a 8 pontos) e alto ( 9 pontos) risco para remoção não eletiva. Conclusão: Recomenda-se a adoção de estratégias preventivas da remoção não eletiva do CCIP baseadas em evidência de acordo com a classificação e fatores de risco do recém-nascido. Além disso, sugere-se evitar a inserção de múltiplos cateteres, a posição não central da ponta do CCIP, e a instalação de cateteres de silicone de única via para a administração de cinco ou mais classes de soluções endovenosas. / Background: Peripherally Inserted Central Catheter (PICC) is a central vascular access device inserted via cannulation of a peripheral vein that allows the infusion of hyperosmolar solutions and medications over a prolonged dwell time. Mechanical and infectious complications can result from its use leading to nonelective removal of the device. A risk score for nonelective removal of PICC-lines that considers jointly a weighted prognostic value of several risk factors can represent a valuable tool for planning the nursing care focused on preventing or modifying identified risk factors, and thereby improving the quality of care. Aim: To develop a risk score for nonelective removal of PICCs in infants. Methods: A cohort study with prospective data collection between August 31, 2010 and August 30, 2012 in 436 infants admitted to a tertiary-level neonatal intensive care unit in São Paulo and submitted to 524PICC insertions. Variables related to the clinical characteristics of the neonate, the technique of catheter insertion, and intravenous therapy that indicated PICC were analysed for their nonelective predictive potential through bivariate analysis, followed by a logistic regression. Predictors were weighted points proportional to their odds ratio in order to develop the risk score. The accuracy of the risk score model was examined by calculating the area under the receiver operating curve (AUC). Results: The risk score was composed of the following risk factors: diagnose of transitory metabolic disorders (hyperglycaemia, hypoglycaemia, disorders of calcium, magnesium, sodium or potassium), previous PICC line insertion, insertion of 2.0 French dual-lumen polyurethane PICC, noncentral tip position, and multiple intravenous solutions in a 1.9 French single-lumen silicone PICC. The accuracy of the risk score was of AUC=0.76 [IC 95%: 0.73-0.78]. Its application allowed classify newborns into three nonelective removal risk categories: a low-risk group (0-3 points), a moderate-risk group (4-8 points), and a high-risk group ( 9 points). Conclusion: It is recommended the adoption of evidence-based preventive measures according to the classification and risk factors of the newborn in order to avoid nonelective removal of PICC. The avoidance of repeated PICC insertions, noncentral tip position, and placement of single-lumen silicone PICCs for administration of five or more intravenous solutions is suggested.