Causes and Risk Factors of Hemodialysis Catheter Infection in Dialysis Patients: A Prospective Study

Objectives: Infectious central venous catheter (CVC) complications, including mortality and care and hospitalization costs, are still a major clinical concern. This study aimed to determine the prevalence of hemodialysis catheter infection and its risk factors among hemodialysis patients. Methods: The present research was a descriptive, prospective cross-sectional study on hemodialysis patients in Babol hospitals during 2020 - 21. The participants' demographic information and some relevant data on clinical variables (namely underlying diseases, cause of dialysis, and cause of catheter removal) and catheter-related variables (namely catheter location, frequency of catheter placement, and apparent signs of catheter site) were collected and recorded directly and systematically during surgery post-surgery. Results: One hundred and twenty-two patients with temporary double-lumen acute hemodialysis catheters for dialysis, including 56 women (45.9%), were included in this study, the mean age of whom was 58.9 ± 16.4 years. Twenty-two patients (18%) developed a catheter-induced systemic infection. There was no significant relationship between the catheter site and its removal inducing infection (P > 0.05). The frequencies of microorganisms causing catheter infection included gram-positive Staphylococcus epidermis (59%) and Staphylococcus aureus (31.8%). Moreover, there was no significant correlation between demographic variables and clinical history with systemic infection induced by catheterization. Conclusions: The rate of catheter-induced infection is relatively high among patients since sterile instructions were observed during catheterization; therefore, it is recommended to pay more attention to the care and dressing of the catheter site.

Clinical and paraclinical characteristics of patients undergoing hemodialysis

Introduction: End-stage renal disease (ESRD) is an irreversible decrease in kidney function with severe consequences. Objectives: The aim of this study was to investigate clinical and paraclinical characteristics of hemodialysis patients. Patients and Methods: This study was a descriptive-analytical performed on 105 patients undergoing hemodialysis referred to Bou Ali and Velayat hospitals in Qazvin. The data were included age, gender, duration of dialysis, kind of vascular access, kind of catheter, site of catheters, weight, height, systolic and diastolic blood pressure, kind of flux, use of midodrine, kind of dialysis solution, number of dialysis per week, calcium (Ca), iron, total iron binding capacity (TIBC), ferritin, parathyroid hormone (PTH), Kt/V, blood urea nitrogen (BUN) and creatinine (Cr). The data were analyzed using SPSS version 21. Results: The mean age of the patients was 60.97±15.13 years and 44.8% of the patients were females. The mean number of dialysis per week was 2.84 times with a mean duration of 3.90 years. The mean Cr level was 8.89±3.14 mg/dL. Males had higher level of BUN (55.91±16.06 mg/dL versus 65.24±17.53 mg/ dL, P=0.006) and Cr (8.09±2.43 mg/dL versus 9.59±3.47 mg/dL, P=0.010). Arteriovenous fistula/AVF was the most common vascular access (76.2% of cases). With increasing BUN, number of dialysis per week and weight, the level of Cr increases significantly (P<0.05). In the younger patients, Cr showed low level compared to the older patients. Conclusion: The number of dialysis per week, weight and BUN level is factors to predict the level of Cr and with increasing these factors, the level of Cr increases. The mean Cr level was high which showed inadequacy of hemodialysis in these patients. The level of Cr and BUN is higher in men.

Aspergillus Genus and Its Various Human Superficial and Cutaneous Features

Superficial and cutaneous aspergillosis is a rare fungal disease that is restricted to the outer layers of the skin, nails, and the outer auditory canal, infrequently invading the deeper tissue and viscera, particularly in immunocompromised patients. These mycoses are acquired through two main routes: direct traumatic inoculation or inhalation of airborne fungal spores into paranasal sinuses and lungs. Lesions are classified into three categories: otomycosis, onychomycosis, and cutaneous aspergillosis. Superficial and cutaneous aspergillosis occurs less frequently and therefore remains poorly characterized; it usually involves sites of superficial trauma—namely, at or near intravenous entry catheter site, at the point of traumatic inoculation (orthopaedic inoculation, ear-self-cleaning, schizophrenic ear self-injuries), at surgery incision, and at the site of contact with occlusive dressings, especially in burn patients. Onychomycosis and otomycosis are more seen in immunocompetent patients, while cutaneous aspergillosis is widely described among the immunocompromised individuals. This paper is a review of related literature.

Hematocrit Sign Elucidates Cause of Abdominal Pain

A 78-year-old male with chronic kidney disease on peritoneal dialysis developed unprovoked bilateral pulmonary embolisms. He was started on IV unfractionated heparin, but shortly thereafter developed severe pain and a small firm abdominal nodule near his dialysis catheter site. The diagnosis was unknown, and the initial plan was watchful waiting, until point-of-care ultrasound (POCUS) was used. POCUS revealed an ovoid mass with hyperdensity in the gravity dependent regions with spontaneous movement. This appearance was classic for the hematocrit sign. When combined with the clinical presentation, this was concerning for a rectus sheath hematoma. An urgent CT of the abdomen confirmed this several hours later. POCUS allowed for rapid bedside diagnosis, which expedited appropriate care in a potentially life-threatening situation.

A Curious Case of MRSA Bacteremia and Septic Pulmonary Embolism Secondary to Peripheral Venous Catheter

Background. Central venous catheters (CVCs) have been frequently associated with septic thrombophlebitis, bacteremia, and septic emboli. Right-sided infective endocarditis is seen concurrently in patients with septic pulmonary emboli. A case of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and septic pulmonary emboli secondary to infected peripheral venous catheter (PVC) is reported. Transesophageal echocardiogram (TEE) showed no evidence of infective endocarditis. Case Presentation. A 44-year-old female presented to E.R. with left upper extremity pain and swelling at the previously inserted peripheral 18-gauge intravenous catheter site. She also had chest pain, which worsened with inspiration. The patient was found to be in septic shock. Her clinical condition deteriorated acutely. Right upper extremity deep venous thrombosis (DVT) and pulmonary emboli were seen on imaging. Blood cultures grew MRSA. Transthoracic and transesophageal echocardiograms showed no vegetations. The patient responded well to appropriate antibiotics and anticoagulation. Conclusion. Peripherally inserted catheters are an important portal for pathogen entry and need periodic site assessment and frequent evaluation of their need for insertion. Septic pulmonary emboli can also be seen without any evidence of right-sided infective endocarditis.

Minimal Incision Venectomy for Peripheral Septic Thrombophlebitis

Peripheral septic thrombophlebitis is an uncommon but potentially lethal condition fraught with systemic complications. Optimal treatment calls for surgical excision of the inflamed venous segment, followed by antimicrobial therapy. However, the extended skin incision and meticulous flap elevation of conventional venectomy leaves substantial residual scarring. Herein, we detail a minimal incision venectomy performed for peripheral septic thrombophlebitis in a 55-year-old man. The patient was initially admitted for conservative management of intracranial hemorrhage but subsequently developed high fever and hypotension. An abscessed intravenous catheter site of the left forearm was the apparent source. Following emergency drainage and serial irrigation, surgical venectomy was undertaken to radically remove the septic focus, excising a 10-cm segment of infected vein through a separate proximal incision. After the procedure, the patient’s recovery was complete and free of complications at postoperative 6-month visit. Under appropriate indications, minimal incision venectomy can be an effective therapeutic alternative with minimal scarring.

A New Method for the Measurement of International Normalized Ratio in Hemodialysis Patients with Heparin-Locked Tunneled Dialysis Catheters

Background. To measure International Normalized Ratio (INR) in hemodialysis patients with tunneled dialysis catheters (TDCs), blood sampling is frequently obtained via the catheter at the start of the session. INR measurements via finger-prick point of care testing (POCT) and via blood sampling taken from the dialysis circuit are evaluated as alternatives. Methods. In 14 hemodialysis patients with TDCs, treated with vitamin K antagonists (VKA), INR measurements via POCT were compared with plasma INR samples taken via the catheter at the start of dialysis and via the dialysis circuit after 30 and 60 minutes during 3 nonconsecutive dialysis sessions. Results. Blood samples taken at the start of dialysis at the catheter site were frequently contaminated with heparin originating from the locking solution (unfractionated heparin concentration (UFH) >1.0 IU/ml in 13.2%). POCT INR at the start of dialysis was not different from plasma INR after 30 and 60 minutes (Wilcoxon test p = 0.113 , n = 37, and p = 0.631 , n = 36, respectively). Moreover, there was no difference between POCT INR at the start of dialysis and POCT INR after 30 and 60 minutes (Wilcoxon test p = 0.797 and p = 0.801, respectively; n = 36). Passing and Bablok regression equation was used, y = 0.460 + 0.733x; n = 105. Treatment decisions based on these 2 methods showed a very good overall agreement (kappa = 0.810; 95% CI: 0.732–0.889; n = 105). Conclusions. Measuring plasma INR via the TDC at the start of dialysis should be abandoned. Measuring POCT INR via a finger prick at the start or even after 30 to 60 minutes is an alternative. The most elegant alternative is to take plasma INR samples via the dialysis circuit 30 minutes or later after the start of the dialysis.

Comparison of global end-diastolic volume index derived from jugular and femoral indicator injection: a prospective observational study in patients equipped with both a PiCCO-2 and an EV-1000-device

Transpulmonary thermodilution (TPTD)-derived global end-diastolic volume index (GEDVI) is a static marker of preload which better predicted volume responsiveness compared to filling pressures in several studies. GEDVI can be generated with at least two devices: PiCCO and EV-1000. Several studies showed that uncorrected indicator injection into a femoral central venous catheter (CVC) results in a significant overestimation of GEDVI by the PiCCO-device. Therefore, the most recent PiCCO-algorithm corrects for femoral indicator injection. However, there are no systematic data on the impact of femoral indicator injection for the EV-1000 device. Furthermore, the correction algorithm of the PiCCO is poorly validated. Therefore, we prospectively analyzed 14 datasets from 10 patients with TPTD-monitoring undergoing central venous catheter (CVC)- and arterial line exchange. PiCCO was replaced by EV-1000, femoral CVCs were replaced by jugular/subclavian CVCs and vice-versa. For PiCCO, jugular and femoral indicator injection derived GEDVI was comparable when the correct information about femoral catheter site was given (p = 0.251). By contrast, GEDVI derived from femoral indicator injection using the EV-1000 was obviously not corrected and was substantially higher than jugular GEDVI measured by the EV-1000 (846 ± 250 vs. 712 ± 227 ml/m2; p = 0.001). Furthermore, measurements of GEDVI were not comparable between PiCCO and EV-1000 even in case of jugular indicator injection (p = 0.003). This is most probably due to different indexations of the raw value GEDV. EV-1000 could not be recommended to measure GEDVI in case of a femoral CVC. Furthermore, different indexations used by EV-1000 and PiCCO should be considered even in case of a jugular CVC when comparing GEDVI derived from PiCCO and EV-1000.