1. Types of urinary cath
Internal: foley, suprapubic
External: texas or condom catheters
2. Indications for use of urine catheters
-ICU/critically ill patients for close monitoring of UOP, Strict Is/Os.
-Surgical patients (all surg patients within 24 hours of surgery, surgery on contiguous/pelvic structure for a while, anyone with epidural who can't get up)
-Medical indications:
-acute retention/outlet obstruction
-hematuria + clots
-intravesicular delivery of drugs or irrigation
-neurogenic bladder
-prolonged immobilization  (sedation, parlysis, trauma)
-urinary incontinence in people with pelvic wounds/ulcers that youare trying to keep clean or heal
-end of life comfort care
3. NOT indications
-Incontinence, older people who have trouble getting up
-Specimen collection
-Provider convenience, patient request.
4. Catheter Associated UTIs 
-Bacteriuria occurs at 3-8% a day.
-10-25% of patients will develop clinically significant sx of UTI
-20% of hospital bacteremias are from foleys
-Usually MDR bugs.
-Prevent these by avoiding putting one in, pulling it out as soon as possible
5. Types of lines

	Peripheral	Central
Catheters		Temporary: -PICC (single or double lumen) -Triple lumen -Quintons (temporary dialysis): shorter, two lumens, often red and blue -Cordis (introducers- usually shock/trauma/surgery) Less temporary: -hickman-- tunneled dialysis catheters start in the chest, insert into the IJ. Vs Quinton are in the neck. -port a cath
Vessel		-IJ: all central lines  -Subclavian: portacath  -femoral: all but portacath
Location	IV access for 2-3days	Meds that require central lines (chemo, tpn, pressors) Procedures (plasma exchange, dialysis) Monitoring (CVP, swan-ganz_ Long term meds (home IV abx)
Complications	Extravasation, cellulitis, thrombophlebitis	Bleeding, arterial puncture, bacteriemai, pneumothorax, thrombosis, air embolism

6. Central line associated blood stream infection  
-8% of hosp patients get a central line
-Risk factors: ICU, chronic ill, immunocompromised, BM transplant, TPN administration (huge risk), how long its in, sterile insertion vs crash insertion, risk of infection from highest to lowest: nontunned > tunneled > implanted
7. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.
Marik et al, Crit Care Med. 2012 Aug
BACKGROUND:
Catheter-related bloodstream infections are an important cause of morbidity and mortality in hospitalized patients. Current guidelines recommend that femoral venous access should be avoided to reduce this complication (1A recommendation). However, the risk of catheter-related bloodstream infections from femoral as compared to subclavian and internal jugular venous catheterization has not been systematically reviewed.
OBJECTIVE:
A systematic review of the literature to determine the risk of catheter-related bloodstream infections related to nontunneled central venous catheters inserted at the femoral site as compared to subclavian and internal jugular placement.
DATA SOURCES:
MEDLINE, Embase, Cochrane Register of Controlled Trials, citation review of relevant primary and review articles, and an Internet search (Google).
STUDY SELECTION:
Randomized controlled trials and cohort studies that reported the frequency of catheter-related bloodstream infections (infections per 1,000 catheter days) in patients with nontunneled central venous catheters placed in the femoral site as compared to subclavian or internal jugular placement.
DATA EXTRACTION:
Data were abstracted on study design, study size, study setting, patient population, number of catheters at each insertion site, number of catheter-related bloodstream infections, and the prevalence of deep venous thrombosis. Studies were subgrouped according to study design (cohort and randomized controlled trials). Meta-analytic techniques were used to summarize the data.
DATA SYNTHESIS:
Two randomized controlled trials (1006 catheters) and 8 cohort (16,370 catheters) studies met the inclusion criteria for this systematic review. Three thousand two hundred thirty catheters were placed in the subclavian vein, 10,958 in the internal jugular and 3,188 in the femoral vein for a total of 113,652 catheter days. The average catheter-related bloodstream infections density was 2.5 per 1,000 catheter days (range 0.6-7.2). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian/internal jugular sites in the two randomized controlled trials (i.e., no level 1A evidence). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian sites. The internal jugular site was associated with a significantly lower risk of catheter-related bloodstream infections compared to the femoral site (risk ratio 1.90; 95% confidence interval 1.21-2.97, p=.005, I²=35%). This difference was explained by two of the studies that were statistical outliers. When these two studies were removed from the analysis there was no significant difference in the risk of catheter-related bloodstream infections between the femoral and internal jugular sites (risk ratio 1.35; 95% confidence interval 0.84-2.19, p=0.2, I=0%). Meta-regression demonstrated a significant interaction between the risk of infection and the year of publication (p=.01), with the femoral site demonstrating a higher risk of infection in the earlier studies. There was no significant difference in the risk of catheter-related bloodstream infection between the subclavian and internal jugular sites. The risk of deep venous thrombosis was assessed in the two randomized controlled trials. A meta-analysis of this data demonstrates that there was no difference in the risk of deep venous thrombosis when the femoral site was compared to the subclavian and internal jugular sites combined. There was, however, significant heterogeneity between studies.
CONCLUSIONS:
Although earlier studies showed a lower risk of catheter-related bloodstream infections when the internal jugular was compared to the femoral site, recent studies show no difference in the rate of catheter-related bloodstream infections between the three sites.
8. Don't use someone's tunneled dialysis catheter for anything but dialysis, because the more times you access it the higher the risk of infection and thrombosis.
9. Pressure ulcer risk & prevention
Braden skin index from 1-4 in 6 areas : sensory perception, moisture, activity, mobility, nutrition, friction, shear. High risk if score <=18. Sensitivity 70-90, specificity 60-80
-Pressure relief: turning in bed q2 hours, foam padding, air beds.
-Make them walk
-Treat incontinence
10. Pressure ulcer grades: 
-Category/Stage I: Non-blanchable erythema
-Category/Stage II: Partial thickness
-Category/Stage III: Full thickness skin loss
-Category/Stage IV: Full thickness tissue loss
-Unstageable/Unclassified: Full thickness skin or tissue loss – depth unknown
-Suspected Deep Tissue Injury – depth unknown