Contralateral sialadenitis after resection of a right cerebellar metastasis: illustrative case

BACKGROUND Acute postoperative sialadenitis is a rare and potentially morbid complication of cranial neurosurgery. This rapidly progressive, unilateral neck swelling often presents within hours of extubation. Diagnosis is made by imaging and exclusion of other causes of etiologies, such as neck hematoma, sialolithiasis, and dependent soft tissue edema. OBSERVATIONS The authors presented a case of acute postoperative sialadenitis after suboccipital resection of a right cerebellar metastasis. Shortly after extubation, extensive left-sided neck swelling was apparent in the postanesthesia care unit. No central lines were placed during the procedure. Imaging revealed submandibular gland edema and fluid accumulation in the surrounding tissue. The patient was managed conservatively with steroids, antibiotics, and warm compresses, with complete resolution of symptoms 2 weeks after the procedure. LESSONS This case emphasizes the broad differential of acute neck swelling after cranial surgery. Physical examination of the neck and airway protection should guide initial treatment. If a patient is stable, bedside ultrasound and computed tomography can be helpful with the differential diagnosis. Here the authors proposed an algorithm for diagnosis and treatment of acute neck swelling after cranial surgery.

Agronomic performance of maize hybrids for forage production in the 2019/2020 harvest

Maize has great economic prominence in national and international agribusiness, being used for various purposes such as grain use and in the form of bulky (silage). This study aimed to evaluate the agronomic characteristics of twelve maize hybrids for silage production in Inconfidentes-MG. Twelve hybrids were used: 20A78PW, 2B512PW, 2B533PW, 2B688PW, 30F53LEPTERA, AG8740-PRO3, DKB345-PRO3, DKB363-PRO3, LG3055-PRO3, LG6036-PRO3, MAXIMUS-VIP3, and MG652PW. The treatments were implanted in a randomized block design (CBD) containing three repetitions. The experimental plots consisted of four lines of five meters in length and 0.8 m spacing between rows, with the two central lines as useful areas. The parameters evaluated were green matter productivity, dry matter productivity, plant height, ear height, average stalk thickness, cutting window, flowering, and cycle. The hybrids 20A78PW; 2B533PW; DKB345-PRO3, and DKB363-PRO3 presented the highest cut-off window values in relation to the others. LG3055-PRO3 hybrid presented the smallest cut-off window. The hybrids 30F53LEPTERA, AG8740, DKB345-PRO3, LG6036-PRO3, and MG652PW presented the highest plant height values. No statistical difference was observed between the hybrids for the variables: green matter productivity, ear height, and stalk thickness. Hybrids AG8740, DKB345-PRO3, LG6036-PRO3, and MG652PW obtained the highest dry matter productivity values. Hybrids 20A78PW, 2B533PW, DKB345-PRO3, and DKB363-PRO3 presented the lowest male and female flowering time. Hybrid DKB345-PRO3 stood out, showing great potential to be recommended and cultivated by silage producers.

777. Implementation of Antimicrobial Impregnated Catheters to Reduce Central Line Associated Bloodstream Infections (CLABSI) in a Pediatric Setting

Background Antimicrobial impregnated catheters (AIC) are one strategy to prevent CLABSI with existing data for central lines required for short duration, however, the strength of evidence, particularly for children, is lacking. Recent 3-year CLABSI data at our institution show 60 (51%) infections occurred in central lines within 8 weeks of insertion, suggesting an opportunity for evaluation of an intervention targeting this time frame. We implemented AIC to evaluate their effectiveness in reducing CLABSI standardized infection ratio (SIR) in patients requiring central venous access for less than 8 weeks. We also monitored for complications (malfunction, line exchange, fungal infection). Methods A stepped wedge observational design was used to implement Minocycline + Rifampin impregnated catheters in a rolling fashion across the institution. Children > 3kg were eligible if admitted to a participating unit and required central venous access through a peripherally inserted central catheter (PICC), non-tunneled catheter, or tunneled non-cuffed femoral catheter for < 8 weeks. Units, prioritized based on CLABSI SIR, were added to the intervention monthly until AIC were used throughout the institution. A multidisciplinary team (infectious diseases and infection control experts, CLABSI leaders, unit-based physicians and nurses, proceduralists, supply chain) met weekly to facilitate implementation, assess for CLABSI and monitor for complications. Figure 1. Study design. This figure describes the stepped wedge study design where units were phased into the invention on a rolling monthly basis allowing for comparison between and within units. The shaded boxes represent time periods when units were using antimicrobial impregnated catheters and the white boxes represent time periods when units were using standard non-impregnated catheters. Results AIC were systematically implemented over a 7-month period. The institution’s CLABSI SIR decreased from 0.80 to 0.59 during this timeframe. There were no NHSH defined CLABSI in patients with an AIC during the intervention. Obstacles included shortage of catheters due to supply chain disruption, adjustment of technique for line insertion and cracked/broken lines. Infections and complications were reviewed by the multidisciplinary team and compared to historical rates with non-impregnated lines. This figure shows the institution’s rolling 12-month SIR during the intervention period. Conclusion CLABSI SIR decreased at our institution during the intervention period. While many efforts likely led to this reduction (optimizing maintenance bundle, unit based CLABSI initiatives), we believe the use of AIC contributed to this improvement. There were no pediatric-specific safety events identified during implementation. Disclosures Ravi Jhaveri, MD, AstraZeneca (Consultant)Dynavax (Consultant)Elsevier (Other Financial or Material Support, Editorial stipend as Co-EiC, Clinical Therapeutics)Hologic (Consultant)Seqirus (Consultant)

1128. Antibiotic Stewardship in Nonoperative Management of Perforated Appendicitis: Oral Antibiotics Are an Alternative

Background Standard of care of nonoperative appendicitis patients involves ongoing antibiotic therapy. Yet, there is variability regarding the decision to continue outpatient parenteral antibiotic treatment (OPAT) or transition to oral (PO) antibiotics. We review antibiotic susceptibility patterns aiming to help guide antibiotic choice and reduce the need for OPAT. Methods Single center retrospective study reviewing pediatric inpatients who underwent nonoperative management of perforated appendicitis with cultures obtained during drainage by Interventional Radiology (IR). We reviewed age, ethnicity, hospitalization length, antibiotic choice, route and duration, and culture data. Results Forty-six patients underwent nonoperative medical management for appendicitis (23[50%] 5-12 year olds (yo); 16[35%] 12-< 18yo; 23[50%] Latino;13[28%] White, 11[24%] Other; 5[11%] Asian; 1[2%] Black). Thirty-eight [83%] patients went home on OPAT, 6[13%] on PO, and 2[4%] completed therapy while inpatient. Time from admission to IR drainage was 1.9 ± 2.8 days (34[75%] within 24 hours of admission, 3[8%] within 24-48, and 2[5%] within 48-72). Duration of hospital stay was 9.7 ± 4 days (PO) and 5.9 ± 2.7 days (OPAT). Duration on antibiotics was 20 ± 9.3 (PO) and 18.4 ± 4.9 days (OPAT). Labs on admission and discharge are compared in Table 1. Eight [17%] patients were readmitted due to complications, 38[83%] went home with a drain, and 20[43%] had a fecalith on CT scan. Based on culture susceptibilities of the 38 OPAT patients, 29[76%] had oral antibiotics as an option. The three most common organisms in those sent home on OPAT included Enterococcus faecalis (38[100%]), Bacteroides spp (33[87%]) and Escherichia coli (27[71%]) (Figure 1). All patients who grew Pseudomonas aeruginosa had a PO option; similarly with 93% of E. coli, 81% of α-hemolytic Streptococcus spp, and 76% of E. faecalis. Conclusion Nearly 80% of patients sent home on OPAT had PO antibiotic regimens options based on the culture results & susceptibility profiles. This data indicates that using cultures and susceptibility data can help guide antibiotic management, significantly reducing PICC line placement and likely reduce healthcare costs and complications associated with central lines. Disclosures All Authors: No reported disclosures

The Venerable Subclavian Line

In this treatise, we will address one of the higher-risk procedures, subclavian vein cannulation, that a practitioner may undertake in the care of complex patients. All cardiothoracic surgeons and their trainees will need, on occasion, to put in central lines in a variety of circumstances, including in the operating room, in the intensive care unit, in emergency circumstances, and, occasionally, when other practitioners have been unsuccessful in their attempts to place a central line. We will describe, in detail, the anatomy of the subclavian vein, the preparation of the patient for subclavian vein cannulation, the infraclavicular approach to cannulation of the vein, and a few notes about the supraclavicular approach to the subclavian vein. It is self-evident that the priorities of central venous cannulation include safety of insertion, minimizing clot formation, and avoiding infection. We will dwell primarily on the principles of safe subclavian line insertion.

Use of Topical Nitroglycerine in the Neonatal Population Following Peripheral Tissue Ischaemia: Case Report and Updates about Safety Concerns

Neonatal thrombosis is a well-described morbidity occurring in the neonatal intensive care unit. Critically ill neonates are most vulnerable to developing thrombosis with serious complications. Fingers and toes ischaemia secondary to vascular occlusion following central lines insertion remains an uncommon occurrence. The therapeutic approach for peripheral tissue injury using local warming, anticoagulants, thrombolytics or topical hyaluronidase showed limited benefits and potential side effects. Here we report an unusual case of finger ischaemia treated successfully using topical nitroglycerine. This complements previous reports confirming the efficacy and safety of this drug and highlighting its potential benefit in neonates.

Potential Risks for and Prognoses After Infections and Antimicrobial use Among Hemodialysis Outpatients: A Prospective Study

Background: The aims of this study were to determine the prevalence and characteristics of infections as well as the use of antimicrobials among hemodialysis outpatients. Methods: We used the dialysis event surveillance protocol to conduct a prospective study in 2019. Results: Totally 180 outpatients who received maintenance hemodialysis were included in the cohort study. The total number of dialysis events was 53 in 38 patients. Among the collected events, 42 (79.25%) events used intravenous antimicrobial treatments; five (9.43%) had positive blood cultures; and six (11.32%) had pus, redness, or swelling at the access site. Type of vascular access was an influencing factor for infection among hemodialysis outpatients. Blood flow rate on dialysis was another factor influencing infection events, the risk of infection increased in patients who had lower blood flow rate. Additional analysis showed that lower blood flow rate was also observed as adverse impact in patients who used central lines, but not in those with fistulas. And Erythropoietin use was higher in the infection group. Conclusions: Patients who used central lines, and especially patients both with central lines and low blood flow rate, were more vulnerable to infection. Using Erythropoietin was another risk factor for infection in hemodialysis outpatients.

Appearance can be Deceptive- A Case Report on Central Venous Line Complication

Central venous (CV) lines are widely used for anything from rapid fluid resuscitation, to drug administration, to parenteral nutrition, and even for administering hemodialysis. Central lines come in different sizes, types, and sites of administration. Sometimes their use can be associated with complications as well. Our patient is an 85 years old hypertensive, diabetic female presenting with post COVID fibrosis with aspiration pneumonia with septic shock. After admissions in ICU, CV line was inserted through right sub-clavian venous route for administration of essential medications including inotropes. However, forceful backflow of blood was noticed after insertion of CV line raising the suspicion of arterial insertion. It was later confirmed by CXR, ABG and duplex arterial study. Taking appropriate precautions, we were able to remove the CV line safely without any complications. Sometimes minor and easy things like CV like insertion can become life threatening. But with proper knowledge and planning we can overcome any complications. Cardiovasc j 2021; 14(1): 73-75

744 A Quality Improvement Project on Timely Removal of Central Venous Catheters

Introduction Central Line-Associated Blood Stream Infections are associated with high morbidity and mortality. It is essential to ensure quality in insertion, maintenance, and timely removal of central lines. Our ICU follows a protocol to remove unused lines after five days. We have an electronic alert system to monitor these lines, and we wanted to audit its usage and improve its efficacy. Method This project was designed using QI methodology and was carried out in a Level III Surgical ICU. We implemented two PDSA cycles in August and December 2020. After the first cycle, an online survey was performed among ICU doctors to gauge their knowledge of the alert system and local protocols. Based on the above results, an educational session was carried out, showing a step-by-step guide to using the alert system, and a re-audit was done in December. Results The first cycle showed that alerts were created for only 17 (25%) of 68 lines. Also, the survey revealed that about 30% of doctors were unfamiliar with the alert system. After the intervention, adherence to the alert system increased to 65% (alerts for 41 of 63 lines). There was also a significant improvement in the mean number of central line days from 6.4 (SD = 3.1) to 4.2 (SD = 2.8) [P < .05]. Conclusions It is crucial to monitor central lines, and simple educational sessions about local protocols can bring success in implementing sustainable change in quality. We suggest hospitals have systems to monitor the central lines and regularly audit their effectiveness.