Internal jugular vein versus subclavian vein as the percutaneous insertion site for totally implantable venous access devices

Wu S, Huang J, Jiang Z, et al. Internal jugular vein versus subclavian vein as the percutaneous insertion site for totally implantable venous access devices: a meta-analysis of comparative studies. BMC Cancer. 2016 Sep 22;16(1):747. Free full-text.

Results: Twelve studies including 3905 patients published between 2008 and 2015, were included. Our meta-analysis showed that incidences of TIVAD-related infections (odds ratio [OR] 0.71, 95 % confidence interval [CI] 0.48-1.04, P = 0.081) and catheter-related thrombotic complications (OR 0.76, 95 % CI 0.38-1.51, P = 0.433) were not significantly different between the two groups. However, compared with SCV, IJV was associated with reduced risks of total major mechanical complications (OR 0.38, 95 % CI 0.24-0.61, P < 0.001). More specifically, catheter dislocation (OR 0.43, 95 % CI 0.22-0.84, P = 0.013) and malfunction (OR 0.42, 95 % CI 0.28-0.62, P < 0.001) were more prevalent in the SCV than in the IJV group; however, the risk of catheter fracture (OR 0.47, 95 % CI 0.21-1.05, P = 0.065) were not significantly different between the two groups. Sensitivity analyses using fixed-effects models showed a decreased risk of catheter fracture in the IJV group.

Conclusion: The IJV seems to be a safer alternative to the SCV with lower risks of total major mechanical complications, catheter dislocation, and malfunction. However, a large-scale and well-designed RCT comparing the complications of each access site is warranted before the IJV site can be unequivocally recommended as a first choice for percutaneous implantation of a TIVAD.

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Foley or no Foley? Criteria for perioperative Foley placement

One discussion this week included the use of Foley catheters.


Reference: Meddings J, et al. Michigan Appropriate Periopeartive (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: results obtained using the RAND/UCLA Appropriateness Method. BMJ Quality & Safety. 2019 Jan;28(1):56-66. doi:10.1136/bmjqs-2018-008025

Summary: Indwelling urinary catheters are commonly used for patients undergoing general and orthopaedic surgery. Despite infectious and non-infectious harms of urinary catheters, there is limited guidance available to surgery teams regarding appropriate perioperative catheter use.

Meddings et al (2019) used the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method 21 to formally rate the appropriateness of urinary catheter placement and timing for removal across routine general and
orthopaedic surgical procedures in adults, as rated by clinicians in different clinical settings across the US and informed by the available literature involving perioperative urinary catheter use.

foley

(Meddings et al, 2019, p.61)

World Health Organization: In the presence of drains, does prolonged antibiotic prophylaxis prevent SSI?

One discussion this week included surgical drains and antibiotic PPX.


Reference: World Health Organization. Summary of a systematic review on antimicrobial prophylaxis in the presence of a drain and wound drain removal. WHO Surgical Site Infection Prevention Guidelines, Web Appendix 27 (30p.).

Summary: In the WHO SSI prevention guidelines, one of the PICO questions addressed is:

In the presence of drains, does prolonged antibiotic prophylaxis prevent SSI?

  • Population: inpatients and outpatients of any age undergoing a surgical
    operation (any type of procedure) with the presence of postoperative drainage
  • Intervention: prolonged antibiotic prophylaxis postoperatively
  • Comparator: single-dose antibiotic prophylaxis (or repeated intraoperatively
    according to the duration of the operation)
  • Outcomes: SSI, SSI-attributable mortality

Their findings are quoted below:

Seven RCTs were identified with an SSI outcome comparing prolonged antibiotic prophylaxis in the presence of a wound drain vs. single-dose perioperative prophylaxis, possibly repeated intraoperatively according to the duration of the procedure. The number of days for antibiotic prophylaxis prolongation in the postoperative period varied among studies. Three studies prolonged antibiotic administration until the wound drain was removed. In the remaining trials, patients continued intravenous administration for 3 or 5 days. Included patients were adults undergoing several types of surgical procedures (general surgery, kidney transplantation, and pilonidal sinus surgery). One trial evaluated whether prolonged antibiotic prophylaxis reduced the risk of infectious complications for patients undergoing elective thoracic surgery with tube thoracostomy. The antibiotic was continued for 48 hours after the procedure or until all thoracostomy tubes were removed, whichever came first.

Among the 7 RCTs, 6 studies showed no statistically significant difference between prolonged antibiotic prophylaxis in the presence of a wound drain vs. perioperative prophylaxis alone. Only one study reported that prolonged antibiotic prophylaxis reduced the risk of SSI. A meta-analysis of the 7 RCTs showed no statistically significant difference between the effect of prolonged antibiotic prophylaxis in the presence of a wound drain and perioperative prophylaxis alone for the risk of SSI (OR: 0.79; 95% CI: 0.53 –1.20]).

Overall, a low quality of evidence shows that prolonged antibiotic prophylaxis in the presence of a wound drain has neither benefit nor harm in reducing the SSI rate when compared to perioperative prophylaxis alone (single dose before incision and possible intraoperative additional dose/s according to the duration of the operation).