Preventing complications of central venous catheterization

Bilateral pleural effusion and pneumomediastinum: rare complication resulting from punctured left subclavian vein following insertion of PICC line for total parenteral nutrition

This is a rare case of development of bi-lateral chylous pleural effusion (containing parenteral nutrition material) along with pneumomediastinum due to punctured left subclavian vein following insertion of a peripherally inserted central venous catheter (PICC) line. Parenteral nutrition is usually preferred for patients unable to tolerate enteral feeding. Due to hypertonicity of the total parenteral nutrition material, it is usually administered via internal jugular or subclavian vein which have a rapid blood flow; therefore, resulting in adequate mixing. Literature studies are yet to clearly explain the communications between two pleural cavities; therefore, development of bilateral pleural effusions in association with pneumomediastinum makes this case more intriguing. We present the journey of a 43-year-old woman who required insertion of bilateral chest drains, followed by sternotomy and repair of the left subclavian vein after she was found in hypoxic respiratory failure 2 days following insertion of PICC line into her left subclavian vein.

Ultrasound in central venous access for hemodialysis

Central venous cannulation is a frequent need for urgent or scheduled hemodialysis. Many studies confirmed the pivotal role of ultrasound in this procedure. Vascular access guidelines strongly recommend ultrasound guidance. Its usefulness has been demonstrated not only in reducing complications of venipuncture but more recently for the evaluation of central venous catheter (CVC) placement and real-time check for possible complications. The use of ultrasound requires a precise technique for the correct handling of the probe and the needle movement. Different approaches as the out-of-plane, in-plane, and oblique methods are available, enabling the most appropriate for the individual case. Although the learning curve for CVC ultrasound placement is usually fast, formal training and certification for beginners are strongly recommended.

The right supraclavicular fossa ultrasound view for correct catheter tip positioning in right subclavian vein catheterisation: a prospective observational study

Central venous catheter misplacement is common (approximately 7%) after right subclavian vein catheterisation. To avoid it, ultrasound-guided tip navigation may be used during the catheterisation procedure to help direct the guidewire towards the lower superior vena cava. We aimed to determine the number of central venous catheter misplacements when using the right supraclavicular fossa ultrasound view to aid guidewire positioning in right infraclavicular subclavian vein catheterisation. We hypothesised that the incidence of catheter misplacements could be reduced to 1% when using this ultrasound technique. One -hundred and three adult patients were prospectively included. After vein puncture and guidewire insertion, we used the right supraclavicular fossa ultrasound view to confirm correct guidewire J-tip position in the lower superior vena cava and corrected the position of misplaced guidewires using real-time ultrasound guidance. Successful catheterisation of the right subclavian vein was achieved in all patients. The guidewire J-tip was initially misplaced in 15 patients, either in the ipsilateral internal jugular vein (n = 8) or in the left brachiocephalic vein (n = 7). In 12 patients it was possible to adjust the guidewire J-tip to a correct position in the lower superior vena cava. All ultrasound-determined final guidewire J-tip positions were consistent with the central venous catheter tip positions on chest X-ray. Three out of 103 catheters were misplaced, corresponding to an incidence (95%CI) of 2.9 (0.6-8.3) %. Although the hypothesis could not be confirmed, this study demonstrated the usefulness of the right supraclavicular fossa ultrasound view for real-time confirmation and correction of the guidewire position in right infraclavicular subclavian vein catheterisation.

Emergency service results of central venous catheters: Single center, 1042 patients, 10-year experience

BACKGROUND

Central venous catheterization is currently an important procedure in critical care. Central catheterization has important advantages in many clinical situations. It can also lead to different complications such as infection, hemorrhage, and thrombosis. It is important to investigate critically ill patients undergoing catheterization.

AIM

To evaluate the characteristics, such as hospitalization, demographic characteristics, post-catheterization complications, and mortality relationships, of patients in whom a central venous catheter was placed in the emergency room.

METHODS

A total of 1042 patients over the age of 18 who presented to the emergency department between January 2005 and December 2015 were analyzed retrospectively. The patients were divided into three groups, jugular, subclavian, and femoral, according to the area where the catheter was inserted. Complications related to catheterization were determined as pneumothorax, guidewire problems, bleeding, catheter site infection, arterial intervention, and sepsis. Considering the treatment follow-up of the patients, three groups were formed as outpatient treatment, hospitalization, and death.

RESULTS

The mean age of the patients was 60.99 ± 19.85 years; 423 (40.6%) of them were women. Hospitalization time was 11.89 ± 16.38 d. There was a significant correlation between the inserted catheters with gender (P = 0.009) and hospitalization time (P = 0.040). Also, blood glucose, blood urea nitrogen, creatinine, and serum potassium values among the biochemical values of the patients who were catheterized were significant. A significant association was observed in the analysis of patients with complications that develop according to the catheter region (P = 0.001) and the outcome stage (P = 0.001). In receiver operating characteristic curve analysis of hospitalization time and mortality area under curve was 0.575, the 95% confidence interval was 0.496-0.653, the sensitivity was 71%, and the specificity was 89% (P = 0.040).

CONCLUSION

Catheter location and length of stay are important risk factors for catheter-borne infections. Because the risk of infection was lower than other catheters, jugular catheters should be preferred at entry points, and preventive measures should be taken by monitoring patients closely to reduce hospitalization infections.

Ultrasound-guided central venous catheterization via internal jugular vein in a patient with subcutaneous neck emphysema: A case report

In patients with subcutaneous neck emphysema, ultrasound images of the internal jugular vein are unclear due to air bubbles. Central venous catheterization can be safely achieved by pushing the accumulated air laterally using an ultrasound probe.

Angioedema with severe acute abdominal pain: Think of hereditary angioedema

Angioedema can be either mast cell-(histamine-)mediated or bradykinin-mediated. Treatment approaches for the two types are very different, making differential diagnosis critical. Severe acute abdominal pain caused by intestinal angioedema is commonly misdiagnosed, especially when associated with bradykinin-mediated angioedema. After describing a typical clinical scenario and diagnostic journey of a patient with recurrent, undiagnosed abdominal pain due to hereditary angioedema (HAE), a rare variant of bradykinin-mediated angioedema, we delve into the classification and differential diagnosis of the various types of angioedema and provide an overview of appropriate management with an emphasis on the bradykinin-mediated types. Bradykinin-induced angioedema may be inherited or acquired and is infrequent compared to mast cell-mediated angioedema. HAE is a rare disease characterized by recurrent attacks of non-urticarial, nonpruritic edema usually affecting the face, respiratory tract, extremities, gastrointestinal tract, and genitalia. Unlike mast cell-mediated angioedema, painful abdominal symptoms are prevalent in bradykinin-mediated angioedema and are sometimes the only manifestation of an attack, increasing the likelihood of initial misdiagnosis as appendicitis or other forms of acute abdomen. It is important for gastroenterologists to be vigilant for the possibility of angioedema pathology in patients presenting with undiagnosed, recurrent, abdominal symptoms to facilitate accurate diagnosis and effective treatment.

Point-of-care Ultrasound-guided Central Venous Catheter Confirmation in Ultrasound Nonexperts

OBJECTIVE

Emerging evidence suggests that chest radiography (CXR) following central venous catheter (CVC) placement is unnecessary when point-of-care ultrasound (POCUS) is used to confirm catheter position and exclude pneumothorax. However, few providers have adopted this practice, and it is unknown what contributing factors may play a role in this lack of adoption, such as ultrasound experience. The objective of this study was to evaluate the diagnostic accuracy of POCUS to confirm CVC position and exclude a pneumothorax after brief education and training of nonexperts.

METHODS

We performed a prospective cohort study in a single academic medical center to determine the diagnostic characteristics of a POCUS-guided CVC confirmation protocol after brief training performed by POCUS nonexperts. POCUS nonexperts (emergency medicine senior residents and critical care fellows) independently performed a POCUS-guided CVC confirmation protocol after a 30-minute didactic training. The primary outcome was the diagnostic accuracy of the POCUS-guided CVC confirmation protocol for malposition and pneumothorax detection. Secondary outcomes were efficiency and feasibility of adequate image acquisition, adjudicated by POCUS experts.

RESULTS

Twenty-six POCUS nonexperts collected data on 190 patients in the final analysis. There were five (2.5%) CVC malpositions and six (3%) pneumothoraxes on CXR. The positive likelihood ratios of POCUS for malposition detection and pneumothorax were 12.33 (95% confidence interval [CI] = 3.26 to 46.69) and 3.41 (95% CI = 0.51 to 22.76), respectively. The accuracy of POCUS for pneumothorax detection compared to CXR was 0.93 (95% CI = 0.88 to 0.96) and the sensitivity was 0.17 (95% CI = 0.00 to 0.64). The median (interquartile range) time for CVC confirmation was lower for POCUS (9 minutes [8.5-9.5 minutes]) compared to CXR (29 minutes [1-269 minutes]; Mann-Whitney U, p < 0.01). Adequate protocol image acquisition was achieved in 76% of the patients.

CONCLUSION

Thirty-minute training of POCUS in nonexperts demonstrates adequate diagnostic accuracy, efficiency, and feasibility of POCUS-guided CVC position confirmation, but not exclusion of pneumothorax.

Catheter-related bloodstream infection associated with multiple insertions of the peripherally inserted central catheter in patients with hematological disorders

Patients with hematological disorders are treated with multiple cycles of chemotherapy. As a result, they often require multiple insertions of the peripherally inserted central catheter (PICC) for prolonged periods of time. Although PICCs have been widely used worldwide in various patients, the safety and feasibility of the multiple insertions of the PICC in this population have not been fully verified. We performed a retrospective analysis to clarify the relationship between complications and multiple PICC insertions in patients with hematological disorders who were treated with either chemotherapy or immunotherapy. A total of 651 PICCs were inserted in 261 patients with a median age of 66 years. Acute myeloid leukemia (AML) and non-Hodgkin's lymphoma were the most common diseases in our patient cohort. The total catheter days (CDs) was 29,485 days, with a median catheter duration of 30 days. The rate of catheter-related bloodstream infection (CRBSI) in our patient cohort at high rate of re-insertion was 2.0/1000 CDs. Although multiple PICC insertions were not a risk factor of CRBSI, our findings suggest that a prolonged catheter dwell time may be associated with CRBSI. AML was an important risk factor of CRBSI. While the PICC dwell time depends on the treatment cycle, our findings indicate that it should be limited to approximately 30 days and catheters may be removed and re-inserted as needed.

Inadvertent arterial puncture involving the subclavian artery and the aorta during central venous catheterization: a case report

Background

This case report describes a subclavian vein cannulation that inadvertently led to an arterial puncture with the catheter tip radiologically seen at the level of the aorta. This case emphasizes the importance of postprocedural imaging and the disadvantages of not using ultrasound guidance in central venous catheterization.

Case presentation

A 24-year-old Caucasian man with diabetes mellitus type 1 presented himself to the emergency department due to abdominal pain accompanied by nausea and vomiting. The patient’s vital signs revealed blood pressure of 84/53 mmHg, heart rate of 103 beats per minute, respiratory rate of 18 breaths per minute, and temperature of 98.2 °F (36.7 °C). On physical examination, he was found to have dry oral mucosa with poor skin turgor, with diagnostics showing that he was in diabetic ketoacidosis after running out of insulin for 2 days. The patient was transferred to the intensive care unit to receive a higher level of care. Unfortunately, due to difficulty of peripheral line placement, only a gauge-22 cannula was secured at the left dorsum of the hand. Efforts to replace the current peripheral line were unsuccessful, and a decision to perform a central vein cannulation via the internal jugular vein was made. This was futile as well due to volume depletion, prompting a subsequent right subclavian vein route attempt. The procedure inadvertently punctured the arterial circulation, leading to the catheter tip being visible at the level of the aorta on postprocedure X-ray. The subclavian line was immediately removed with no adverse consequences for the patient. A right femoral line was successfully placed, and continuous management of the diabetic ketoacidosis ensued until normalization of the high anion gap was achieved.

Conclusion

Utilization of real-time ultrasound guidance via the subclavian approach could have allowed for direct visualization of needle insertion to the anatomical structures, guidewire location, and directionality, all of which can lead to decreased complications and improved cannulation success compared with the landmark technique. A leftward direction of the catheter seen on postprocedural X-rays should raise high suspicion of inadvertent catheter placement and immediate correction. This complication should have been prevented if ultrasound guidance had been used.

Simplify long-term venous access via external jugular vein in children

Background

Bone marrow transfer has begun to be widely used in complicated conditions, such as chemotherapy or hemodialysis, following the description of indwelling central venous catheters and demonstrating their suitability in pediatric patients. The widespread use of it has increased the incidence of complications as well. The use of external jugular vein catheterization, which is a safer route compared to the blind route of administration, has topographical difficulties. The findings obtained in this study showed that these difficulties could be overcome. Our study revealed that the catheterization was possible and described a facilitating technique. Of the pediatric patients involved in the bone marrow transfer programs, patients who were deemed eligible candidates for the use of external jugular vein, based on the preoperative assessment, were included in the present study.

Results

No early complication was observed in this study. The central catheter was placed on all patients in the same session. Catheters were inserted using the external jugular vein in 98 patients and percutaneous internal jugular vein in 2 patients. A central catheter was inserted through 105 interventions and 103 incisions in 100 patients. External jugular vein use, which was planned before the procedure, was achieved in 98 patients. The internal jugular vein was selected as the second option in 2 patients. The success rate of external jugular vein use was 95.1%.

Conclusions

The findings obtained in this study suggest that placement of a central catheter using an external jugular vein is an appropriate option. Application difficulties can be overcome. Mechanical and early complications are negligible compared to percutaneous blind techniques. The use of the external jugular vein route is easy, requires less equipment, has few complications, and the success of the procedure is a preoperatively predictable technique. External jugular vein catheterization is a better alternative compared to the Seldinger technique, in the absence of ultrasonography, which enhances the success of the percutaneous technique, and in cases where blind techniques, such as bleeding diathesis, may be unfavorable.

Severe Hyponatremia and Seizure From Peripheral Infusion of Norepinephrine Diluted in Dextrose 5% in Water: A Case Report

Recent studies have demonstrated that vasopressors can be delivered safely through peripheral intravenous lines. While norepinephrine is usually delivered at a concentration of 16 to 32 μg/mL, out of concern for extravasation and interstitial necrosis, some patients receive more dilute norepinephrine solutions through peripheral intravenous catheters. We describe a case of severe hyponatremia and seizure resulting from administration of norepinephrine concentrated at 4 μg/mL in dextrose 5% in water. After the incident, the institutional policy changed to recommend normal saline as the default diluent for peripheral norepinephrine, with a more concentrated option available. The incident also informed similar guidelines at other hospitals.

Positive effect of care bundles on patients with central venous catheter insertions at a tertiary hospital in Beijing, China

Objective

This study was performed to evaluate the effect of care bundles on the prevention of central venous catheter-related bloodstream infection (CRBSI) and improvement of patients’ experience.

Methods

In total, 212 patients with central venous catheter insertions were enrolled in this study. All patients were matched by sex, age, Acute Physiology and Chronic Health Evaluation II score, body mass index, department, and catheter insertion site and were randomly divided into case and control groups (n = 106 each). The control group was given conventional care, and the case group was given care bundles including nurse education, hand hygiene, maximal sterile barrier precautions, bedside observation, and evaluation. The anxiety scores, hospitalization days, CRBSI rate, and degree of satisfaction with hospitalization were compared between the two groups.

Results

The patients’ mean self-rating anxiety scale score and self-rating depression scale score after nursing intervention were significantly lower in the case group than in the control group. The mean number of hospitalization days and CRBSI rate were significantly lower and the satisfaction rate was significantly higher in the case group.

Conclusion

Care bundles are essential for preventing CRBSI. They can improve patients’ psychological state and hospitalization satisfaction and reduce the hospitalization days.

Vascular access, membranes and circuit for CRRT

The advances in the technology for providing continuous renal replacement therapy (CRRT) have led to an increase in its utilization throughout the world. However, circuit life continues to be a major problem. It leads not only to decreased delivery of dialysis but also causes blood loss, waste of disposables, alters dose delivery of medications and nutrition, and increases nurse workload, all of which increases healthcare cost. Premature circuit failure can be caused by numerous factors that can be difficult to dissect out. The first component is the vascular access; without a well-placed, functioning access, delivery of CRRT becomes very difficult. This is usually accomplished by placing a short-term dialysis catheter into either the right internal jugular or femoral vein. The tips should be located at the caval atrial junction or inferior vena cava. In addition to establishing suitable vascular access, a comprehensive understanding of the circuit facilitates the development of a methodical approach in providing efficient CRRT characterized by optimal circuit life. Moreover, it aids in determining the cause of circuit failure in patients experiencing recurrent episodes. This review therefore summarizes the essential points that guide providers in establishing optimal vascular access. We then provide an overview of the main components of the CRRT circuit including the blood and fluid pumps, the hemofilter, and pressure sensors, which will assist in identifying the key mechanisms contributing to premature failure of the CRRT circuit.

Biomechanical analysis of expert anesthesiologists and novice residents performing a simulated central venous access procedure

BACKGROUND

Central venous access (CVA) is a frequent procedure taught in medical residencies. However, since CVA is a high-risk procedure requiring a detailed teaching and learning process to ensure trainee proficiency, it is necessary to determine objective differences between the expert's and the novice's performance to guide novice practitioners during their training process. This study compares experts' and novices' biomechanical variables during a simulated CVA performance.

METHODS

Seven experts and seven novices were part of this study. The participants' motion data during a CVA simulation procedure was collected using the Vicon Motion System. The procedure was divided into four stages for analysis, and each hand's speed, acceleration, and jerk were obtained. Also, the procedural time was analyzed. Descriptive analysis and multilevel linear models with random intercept and interaction were used to analyze group, hand, and stage differences.

RESULTS

There were statistically significant differences between experts and novices regarding time, speed, acceleration, and jerk during a simulated CVA performance. These differences vary significantly by the procedure stage for right-hand acceleration and left-hand jerk.

CONCLUSIONS

Experts take less time to perform the CVA procedure, which is reflected in higher speed, acceleration, and jerk values. This difference varies according to the procedure's stage, depending on the hand and variable studied, demonstrating that these variables could play an essential role in differentiating between experts and novices, and could be used when designing training strategies.

Y-site physical compatibility of hydrocortisone continuous infusions with admixtures used in critically ill patients

PURPOSE

Critically ill patients with septic shock often receive multiple intravenous medications, necessitating either the placement of separate lines for medication administration or administration of medications concurrently through a Y-site connector only where compatibility has been demonstrated. The purpose of this study was to examine the physical compatibility of hydrocortisone infusions and select intravenous medications through a simulated Y site.

METHODS

The medications tested for simulated Y-site physical compatibility with hydrocortisone included acetaminophen, albumin, cefepime, ciprofloxacin, cisatracurium, doripenem, epinephrine, esomeprazole, ibuprofen, levofloxacin, levothyroxine, meropenem, and norepinephrine. Hydrocortisone in solution with 0.9% sodium chloride injection was combined with an equivalent volume of solutions of each test drug at maximum or commercially available concentrations used clinically in intensive care units, as appropriate. The samples were evaluated using turbidimetric measurements and examined visually against light and dark backgrounds to determine physical compatibility. Observations and analyses were completed over a one-hour period at 15-minute intervals beginning immediately after mixing. Each test was performed in triplicate.

RESULTS

All study medications demonstrated visual and/or turbidimetric physical compatibility when combined with hydrocortisone in a simulated Y-site infusion. No medications demonstrated a visual physical incompatibility when combined with hydrocortisone.

CONCLUSION

Acetaminophen, albumin, cefepime, ciprofloxacin, cisatracurium, doripenem, epinephrine, esomeprazole, ibuprofen, levofloxacin, levothyroxine, meropenem, and norepinephrine exhibited physical compatibility with hydrocortisone via Y-site infusion.

Chemoport Insertion-Less Is More

Implantable chemoport is a very useful device for long-term venous access for infusion of chemotherapeutic drugs and other agents. There are few studies from resource poor countries reporting complications of chemoport. The aim of the present study is to evaluate the feasibility of chemoport insertion without image guidance and by closed technique without direct visualisation of a major vein (mainly IJV) and to study the complications associated with the procedure. This was a prospective observational study which analysed 263 patients who underwent chemoport insertion. The medical records of these patients were analysed for the patient characteristics, diagnosis, port-related complications, and their management. A total of 263 patients who were harbouring either locoregionally advanced or metastatic tumour requiring either chemotherapy or targeted treatment or both were included in the study. In total, 133 (50.57%) were female patients and 130 were male patients (49.43%). A total of 236 patients (89.73%) underwent port insertion procedures under local anaesthesia. None of the patients had any major intra-operative complications. Postoperatively, 4 patients (1.52%) were found to have port catheter malposition; 3 out of this 4 were corrected under IITV guidance as a second procedure under local anaesthesia only. One patient (0.38%) required formal removal and replacement of port. Four patients (1.52%) developed IJV thrombosis requiring port removal and anti-coagulation. One patient (0.38%) developed thrombus in the right atrium. There were 2 port site infections (0.74%) requiring port removal (SSI cat. 5). Low complication rates of port insertion were observed in the present, large, prospective study. Complication rates may be further reduced by using a well-designed procedure, experienced surgeons, an aseptic environment, ultrasound-guided puncture, and fluoroscopy with contrast media.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-020-01265-6.

Management of Inadvertent Supra-aortic Arterial Lesions During Central Venous Access Procedures: Report of Six Cases and Proposed Algorithm

Accidental supra-aortic arterial cannulation during central venous catheter (CVC) insertion is a rare and serious complication associated with risk of vascular and neurologic complications. The aim of this study is describing our 6 cases experience and propose a management algorithm. We retrospectively evaluated the diagnosis and treatment of six patients arrived at our Department for accidental supra-aortic arterial cannulation during CVC insertion. They underwent Doppler Ultrasonography (DUS) or Computed Tomography Angiography (CTA) to confirm the arterial damage and to decide the correct therapeutic pathway. Four patients underwent DUS as the shallow location of injured arteries and 2 patients CTA because of the arterial damage deeply located. Surgical procedure with direct arterial suture was performed in four patients. Endovascular treatment with stent graft deployment was carried out in two patients. All procedures were conducted successfully: technical success (immediate hemostasis and vessel patency) was obtained in 100% of the cases. Postoperative imaging (DUS or CTA) confirmed the absence of arterial bleeding and the arterial patency. No perioperative mortality or complications occurred. After a careful review of literature and our case series, we proposed an algorithm to delineate the optimal treatment strategy, explaining that early and careful diagnosis (by DUS or CTA) and prompt repair appear crucial to achieve good outcomes and clarifying that an endovascular technique (stent graft placement or vascular closure device) seems to be the best treatment in these cases. Finally, an open surgical technique could be indicated in case of common carotid artery injury and concurrent catheter passing through the target vein.

CLABSI reduction using evidence based interventions and nurse empowerment: a quality improvement initiative from a tertiary care NICU in Pakistan

OBJECTIVE

Central line associated bloodstream infection (CLABSI) is an important cause of morbidity and mortality in the neonatal intensive care unit (NICU). We designed a CLABSI Prevention Package (CPP) to decrease NICU CLABSI rates, using evidence-proven interventions.

DESIGN

This was a quality improvement (QI) project. Data collection was divided into three phases (pre-implementation, implementation and post implementation). SQUIRE2.0 guidelines were used to design, implement and report this QI initiative.

SETTING

A tertiary care level 3 NICU at the Aga Khan University Hospital (AKUH), Karachi, Pakistan.

PATIENTS

All patients admitted to the AKUH NICU from 1 January 2016 to 31 March 2018 who had a central line in place during their NICU admission.

INTERVENTIONS

CPP used evidence-based interventions focusing on hand hygiene, aseptic central line insertion techniques and central line care, prevention of fungal infections and nurse empowerment.

MAIN OUTCOME MEASURES

CLABSI rates pre and post intervention were recorded. Secondary outcomes were risk factors for CLABSI, device (central line) utilisation ratio, CLABSI related mortality and micro-organism profile.

RESULTS

CLABSI rates decreased from 17.1/1000 device days to 5.0/1000 device days (relative risk (RR)=0.36, CI=0.17-0.74). Device (central line) utilisation ratio declined from 0.30 to 0.25. Out of 613 patients enrolled in our study, 139 (22.7%) died. Mortality was higher in CLABSI group (n=20, 44%) as compared with non CLABSI group (n=119, 21.1%) (p<0.001). Gestational age of <27 weeks was an independent risk factor for CLABSI (RR=4.45, CI=1.10-18.25, p=0.03). A total of 158 pathogens were isolated among which 68 were associated with CLABSI. Gram-negative bacteria 31 (47.7%) were the most common cause of CLABSI. Ninety-seven (61%) micro-organisms were multi-drug resistant.

CONCLUSIONS

CPP was effective in decreasing NICU CLABSI rates and can be used as a model to decrease NICU CLABSI rates in low or middle-income countries.

Spectral characteristics of the internal jugular vein and central venous pressure pulses: a proof of concept study

In this proof-of-concept study the impact of central venous pressure (CVP) on internal jugular veins cross-sectional area (CSA) and blood flow time-average velocity (TAV) was evaluated in eight subjects, with the aim of understanding the drivers of the jugular venous pulse. CVP was measured using a central venous catheter while CSA variation and TAV along a cardiac cycle were acquired using ultrasound. Analysis of CVP, CSA and TAV time-series signals revealed TAV and CSA to lag behind CVP by on average 0.129 s and 0.138 s, with an inverse correlation between CSA and TAV (r= –0.316). The respective autocorrelation signals were strongly correlated (mean r=0.729-0.764), with mean CSA periodicity being 1.062 Hz. Fourier analysis revealed the frequency spectrums of CVP, TAV and CSA signals to be dominated by frequencies at approximately 1 and 2 Hz, with those >1 Hz greatly attenuated in the CSA signal. Because the autocorrelograms and periodograms of the respective signals were aligned and dominated by the same underlying frequencies, this suggested that they are more easily interpreted in the frequency domain rather than the time domain.

Syringe-Free, Long-Axis in-Plane Versus Short-Axis Classic out-of-Plane Approach for Ultrasound-Guided Internal Jugular Vein Catheter Placement in Critically Ill Children: A Prospective Randomized Study

OBJECTIVE

Although pediatric central venous catheterization is performed using ultrasound guidance, it is still a challenge. This study aimed to investigate the efficacy of the syringe-free, long-axis in-plane approach and compared the short-axis classic out-of-plane approach for ultrasound-guided central venous catheter placement in critically ill pediatric patients.

DESIGN

Prospective randomized study.

SETTING

Single institution, tertiary university hospital, pediatric care unit.

PARTICIPANTS

The study comprised 60 patients ages three months to 15 years.

INTERVENTIONS

Participants were randomly divided into two equal groups. Group I (n = 30) incorporated patients who underwent the long-axis, syringe-free in-plane approach, and group II (n = 30) incorporated patients who underwent the short-axis out-of-plane approach.

MEASUREMENTS AND MAIN RESULTS

Performing time, number of needle passes, number of skin punctures, first-pass success rate, and related complications were evaluated. There were no differences between the two groups in terms of demographics and vein-related measurements (p > 0.05). Performing time was statistically shorter in group I compared with group II (32 [25-38] v 58 [42-70] s; p < 0.001). There was no statistical difference between first-pass success rates between groups (group I 86.6% v group II 80%; p = 0.731). There were no significant differences between the groups in the number of needle passes and skin punctures (p = 0.219 and 0.508, respectively). Complications occurred in both groups, but there was no significant difference (4/30 v 7/30; p = 0.317).

CONCLUSIONS

The syringe-free, long-axis in-plane approach can be a safe and fast alternative for pediatric catheterization.

Effects of practitioner's experience on the clinical performance of ultrasound-guided central venous catheterization: a randomized trial

We investigated whether two needle insertion techniques for ultrasound-guided internal jugular vein (IJV) catheterization differ in the number of needling attempts and complication rate between inexperienced and experienced practitioners. A total of 308 patients requiring IJV catheterization were randomly assigned into one of four groups: IJV catheterization performed by inexperienced practitioners using either Seldinger (IE-S; n = 78) or modified Seldinger technique (IE-MS; n = 76) or IJV catheterization performed by experienced practitioners using either Seldinger (E-S; n = 78) or modified Seldinger technique (E-MS; n = 76). All catheterizations were performed under the real-time ultrasound guidance. The number of needling attempts was not significantly different between the two techniques within each experience group (between IE-S vs. IE-MS P = 0.550, between E-S and E-MS P = 0.834). Time to successful catheterization was significantly shorter in the E-S group compared to E-MS group (P < 0.001) while no significant difference between IE-S and IE-MS groups (P = 0.226). Complication rate was not significantly different between the two techniques within each experience group. Practitioner's experience did not significantly affect the clinical performance of needle insertion techniques during ultrasound-guided IJV catheterization except the time to successful catheterization. Regarding the number of needling attempts and complication rate, both techniques could be equally recommended regardless of practitioner's experience.Trial registration: clinicaltrials.gov (https://clinicaltrials.gov/ct2/show/NCT03077802).

Prevention of posterior wall puncture with a self-made needle block

Vascular access is one of the most commonly performed invasive procedures in medicine. Ultrasound-guided vascular access has been shown to improve patient safety, decrease associated complications and increase first attempt success rates, however, the risk for a posterior venous wall puncture (PVWP) still exists. To reduce this complication, needle guides have been used, though, current methods have limited accessibility and generalizability. Thus, the aim of this article is to describe how a self-made needle block constructed with materials present in a central line kit can reduce the incidence of PVWP and its associated complications in novice POCUS users.

Peripheral vascular complications following totally endoscopic cardiac surgery

Background

Clinical application of minimally invasive cardiac surgery has increased annually. Cardiopulmonary bypass is established by peripheral cannulation during minimally invasive cardiac surgery. The methodology of peripheral cannulation has unique characteristics, which have associated risks and complications. Few studies have been conducted on this topic. In this study, we focused on complications of peripheral cannulation in totally endoscopic cardiac surgery.

Methods

Patients who underwent totally endoscopic cardiac surgery with cardiopulmonary bypass established by peripheral cannulation at our institution between January 2019 and June 2020 were reviewed. Specific cannulation strategies and related cannulation complications were noted.

Results

One hundred forty-eight patients underwent totally endoscopic cardiac surgery. One hundred forty-eight cannulations were performed in the femoral artery and vein, and eleven were performed in the internal jugular vein (combined with the femoral vein). The median size of the femoral artery cannula was 22Fr, and that of the venous canula was 24Fr. One patient died of retroperitoneal haematoma due to femoral artery injury. Three patients had postoperative lower limb oedema. One patient had a postoperative diagnosis of femoral vein thrombosis.

Conclusions

Different from cannulation in patients with aortic dissection and aneurysms, femoral artery cannulation is safe in totally endoscopic cardiac surgery. Venous cannulation is characterized by a large-bore venous cannula and a short period of use. There are few reports about complications of venous cannulation. The main complication in this study was mechanical injury, and the key to preventing this injury is meticulous manipulation during surgery.

Risk factors for failure of subclavian vein catheterization: a retrospective observational study

Background and objectives

The aim of this study was to analyze risk factors for failure of subclavian vein catheterization.

Methods

A retrospective analysis of 1562 patients who underwent subclavian vein puncture performed by the same experienced operator at Peking University Cancer Hospital from January 1, 2016 to January 1, 2019 was conducted. The success or failure of subclavian vein catheterization was registered in all cases. Various patient characteristics, including age, gender, body mass index (BMI), preoperative hemoglobin, preoperative hematocrit, preoperative mean corpuscular hemoglobin concentration (MCHC), preoperative albumin, preoperative serum creatinine, puncture needles from different manufacturers and previous history of subclavian vein catheterization were assessed via univariate and multivariate analyses.

Results

For the included patients, landmark-guided subclavian vein puncture was successful in 1476 cases and unsuccessful in 86 cases (success rate of 94.5%). Successful subclavian vein catheterization was achieved via right and left subclavian vein puncture in 1392 and 84 cases, respectively. In univariate analyses, age and preoperative hemoglobin were associated with failure of subclavian vein catheterization. In a multivariate analysis, aged more than 60 years was a risk factor while the central venous access with Certofix® was associated with an increased rate of success (p-values of 0.001 and 0.015, respectively).

Conclusions

This study has demonstrated that patient aged more than 60 years was a risk factor for failure of subclavian vein catheterization while the central venous access with Certofix® was associated with an increased rate of success.

Persistent Left Superior Vena Cava—When a Left-Sided Central Line Does Not Make the Turn: A Case Report

A 59-year-old male presenting for a living nonrelated kidney transplant has an intraoperative left internal jugular central venous catheter placed for operative access and monitoring. Post-anesthesia care unit postoperative chest X-ray shows possible aortic placement as read by radiology. The catheter is confirmed venous on insertion, with monitoring during the operation, and with repeat transduction and venous blood gas results postoperatively. A follow-up computed tomography scan shows findings consistent with persistent left superior vena cava. This can be associated with other cardiac abnormalities and an increased risk of complications, both mechanical and physiological. Care should be taken in patients identified with persistent left superior vena cava to prevent complications in future procedures.

Effect of shoulder positioning on ultrasonic visualisation of the subclavian vein in healthy adults: A prospective observational study

Introduction:

Ultrasound guidance is commonly used during central venous cannulation. Subclavian vein is a commonly chosen site, but previous studies found varying results in the ideal positioning of the shoulder for subclavian vein cannulation. The objective of this study is to determine which shoulder position results in the greatest cross-sectional area of the right subclavian vein for cannulation.

Methods:

In this prospective observational study, ultrasound was performed on healthy adult volunteers to visualise the right subclavian vein in three different shoulder positions: neutral, abduction and retraction. A blinded independent investigator measured the cross-sectional areas by computer software using planimetry method. Statistical analysis was performed by one-way repeated measures analysis of variance.

Results:

Forty-four adults participated in the study. The mean cross-sectional area of the right subclavian vein in shoulder neutral, abduction and retraction positions were 1.05 ± 0.33 cm2, 1.01 ± 0.31 cm2 and 0.82 ± 0.28 cm2, respectively. When compared to shoulder retraction, the cross-sectional areas were significantly increased in shoulder neutral ( P < 0.01) and abduction ( P < 0.01) positions. There was no significant difference between shoulder neutral and abduction position ( P = 0.71).

Conclusion:

Positioning the shoulder in neutral or abduction results in the greatest cross-sectional area of the right subclavian vein and may be more ideal for ultrasound guided cannulation.

To PICC or not to PICC? A cross-sectional survey of vascular access practices in the ICU

PURPOSE

Vascular access patterns in the intensive care unit (ICU) have shifted from non-tunneled central venous catheters (CVCs) towards peripherally inserted central catheters (PICCs). We evaluated perceptions of critical care practitioners regarding these devices and variation in evidence-based practice.

MATERIALS

A 35-question survey on ICU vascular access was deployed in 13 Michigan hospitals. Descriptive statistics summarized responses. Differences in utilization, perceptions and evidence-based practices between PICCs and CVCs, by participant and site-level characteristics, were assessed.

RESULTS

314 of 621 eligible providers responded to the survey (response rate 51%). 15% of providers reported not routinely using ultrasound when placing CVCs. Respondents whom were trainees, from larger hospitals, and from closed ICUs were more likely to use ultrasound (p < 0.001). Additionally, 21% of respondents stated they did not specify number of CVC lumens, while 46% did not specify number of PICC lumens (p < 0.001). The likelihood of specifying PICC lumens increased when vascular access protocols were in place (p = 0.001). 2/3 of respondents (n = 173, 66%) stated more research on ICU vascular access was needed.

CONCLUSION

Variation in guideline-based vascular access practices exists in the ICU. Defined local protocols may improve guideline adherence. Studies evaluating vascular access decisions and patient safety in the ICU appear necessary.

Massive hemothorax after central venous catheter insertion in a patient with multiple trauma

Central venous catheter (CVC) insertion is commonly used in the operating room and intensive care unit to monitor central venous pressure and secure an intravenous route to deliver medications and nutritional support that cannot be safely infused into peripheral veins. However, CVC insertion may be associated with serious complications such as arterial puncture, hematoma, pneumothorax, hemothorax, catheter infections, and thrombosis. Several methods have been recommended to prevent these complications. Here we report a case of massive hemothorax caused by attempts of CVC insertion into the internal jugular vein and subclavian vein in a patient with multiple trauma. CVC placement should be performed or supervised by an experienced physician to decrease the incidence of CVC-related complications. CVC insertion under ultrasound guidance is recommended.

Advances in Hereditary Angioedema: The Prevention of Angioedema Attacks With Subcutaneous C1-Inhibitor Replacement Therapy

Supplemental Digital Content is Available in the Text.

Hereditary angioedema (HAE) is a debilitating condition caused by a functional C1-inhibitor (C1-INH) deficiency and characterized clinically by episodes of subcutaneous or submucosal swelling. C1-INH replacement is highly effective for preventing HAE attacks and can improve health-related quality of life. Once available only for intravenous use, C1-INH is now available as a subcutaneous formulation for self-administration, shown to provide sustained plasma levels of C1-INH and reducing the monthly median HAE attack rate by 95% versus placebo in the phase 3 COMPACT study. Subcutaneously administered C1-INH satisfies multiple unmet needs in the management of patients with HAE.

Alternative Access for Mechanical Circulatory Support

Femoral arterial access is the default strategy for large-bore interventional procedures, including temporary mechanical circulatory support implantation and structural heart therapies, based on superior outcomes and operator ease. In addition to patient size and comorbidities, vessel tortuosity, significant calcification, and diminutive vessel caliber all may make iliofemoral access prohibitively high risk or impossible. Given the increase of large-bore transcatheter procedures, bleeding avoidance strategies are essential and thus novel mechanisms for large-bore access have evolved. This article highlights the advantages, limitations, and practical approaches to the 2 most common percutaneous large-bore alternative access strategies: transaxillary and transcaval access.

Bedside ultrasound as a screening test for the diagnosis of catheter-related bloodstream infection (CRBI)

Purpose

Between 15 and 30% of all nosocomial bacteremias and sepsis are associated with the use of intravascular devices. Catheter-related bloodstream infections (CRBI) are infections in which the organism identified in the blood is also present on the tip of the catheter itself or in a blood sample taken through it. The aim of the study was to evaluate the role of ultrasound in the diagnosis of infections related to the use of central catheters.

Methods

Between January 2018 and June 2019, we carried out a prospective study on 36 patients with a central catheter, such as a central venous catheter (CVC), a central catheter with peripheral insertion (PICC), or a fully implanted central venous catheter (PORT-a-cath) and who had signs and symptoms of infection. These patients were submitted to an ultrasound of the catheter upon arrival in the ward in case of suspected infection, or at the time of the onset of signs and symptoms of infection (if these arose during hospitalization). Patients with a central catheter but without signs and symptoms of infection were not included in the study.

The end point of the study was to evaluate sensitivity (SENS), specificity (SPEC), positive and negative predictive value (PPV-NPV) and overall diagnostic accuracy (ODA) of ultrasound in the diagnosis of CRBI through Receiver Operating Characteristic (ROC) curve analysis.

Results

US showed a SENS of 94%, a SPEC of 84%, a PPV of 84%, an NPV of 94% and an ODA of 88.8% for the diagnosis of CRBI.

Conclusions

Preliminary data from our study show that US of intravascular devices has a high SENS and SPEC in the diagnosis of CRBI, and can, therefore, be used as a valid tool to decide whether to remove the device early or leave it in place.

Wireless, implantable catheter-type oximeter designed for cardiac oxygen saturation

Accurate, real-time monitoring of intravascular oxygen levels is important in tracking the cardiopulmonary health of patients after cardiothoracic surgery. Existing technologies use intravascular placement of glass fiber-optic catheters that pose risks of blood vessel damage, thrombosis, and infection. In addition, physical tethers to power supply systems and data acquisition hardware limit freedom of movement and add clutter to the intensive care unit. This report introduces a wireless, miniaturized, implantable optoelectronic catheter system incorporating optical components on the probe, encapsulated by soft biocompatible materials, as alternative technology that avoids these disadvantages. The absence of physical tethers and the flexible, biocompatible construction of the probe represent key defining features, resulting in a high-performance, patient-friendly implantable oximeter that can monitor localized tissue oxygenation, heart rate, and respiratory activity with wireless, real-time, continuous operation. In vitro and in vivo testing shows that this platform offers measurement accuracy and precision equivalent to those of existing clinical standards.

Safe Central Venous Access in an Overburdened Health System

A previously healthy man, intubated in the intensive care unit (ICU) for respiratory failure due to coronavirus disease 2019 (COVID-19), required central venous access for vasopressor infusion. The intensivists were occupied managing other critically ill patients, so an available intern attempted to place a triple-lumen catheter in the right internal jugular vein using only anatomic landmarks for guidance. When the access needle was inserted, pulsatile return of blood was noted.

Chest radiography for simplified evaluation of central venous catheter tip positioning for safe and accurate haemodynamic monitoring: a retrospective observational study

OBJECTIVES

The tip-to-carina (TC) distance on a simple chest X-ray (CXR) has proven value in the determination of correct central venous catheter (CVC) positioning. However, previous studies have mostly focused on preventing the atrial insertion of the CVC tip, and not on appropriate positioning for accurate haemodynamic monitoring. We aimed to assess whether the TC distance could detect the passage of the CVC tip into the superior vena cava (SVC) and the right atrium (RA), and to accordingly suggest cut-off reference values for these two aspects.

DESIGN

Retrospective observational cohort study.

SETTING

Single urban tertiary level academic hospital.

PARTICIPANTS

479 patients who underwent CXR and chest CT scan after the insertion of a CVC with a 24-hour interval during the study period.

INTERVENTION

The TC distance was measured on CXR, and the position of the CVC tip was assessed on the chest CT images. The TC distance was described as a negative or positive number if the CVC tip was above or below the carina, respectively. Receiver-operating characteristics curve analyses were conducted to ascertain the TC distance to detect SVC entrance and RA insertion of CVC tip.

RESULTS

The TC distance could significantly detect both SVC entrance and RA insertion (p<0.001 for both; area under curve 0.987 and 0.965, respectively), with a reference range of -6.69 to 15.61 mm.

CONCLUSION

The TC distance in CXR is a simple and precise method to confirm not only the safe placement of the CVC tip but also its optimal positioning for accurate haemodynamic monitoring.

Changes in Central Venous Catheter Use in the Hematology Unit with the Introduction of Ultrasound Guidance and a Peripherally Inserted Central Venous Catheter

Objective A central venous catheter (CVC) is often needed to treat hematologic diseases, but it is accompanied by many complications. Ultrasound guidance (USG) or a peripherally inserted central venous catheter (PICC) can reduce such complications. Meterials We collected data of patients with attempted CVC placement in our hematology unit in 2012 (before introduction of USG and PICC) and 2018 (after introduction) and compared both periods. Results In total, 187 CVC insertions were attempted in 2018 and 198 in 2012. USG was used 154 times (82%) in 2018 and 4 times (2%) in 2012 (p<0.001). The success rates of insertion were 95% in 2018 and 89% in 2012 (p=0.063). The incidence of acute complications was 4.3% in 2018 and 9.1% in 2012 (p=0.069). The incidence of CVC removal owing to delayed complications was 26% in 2018 and 21% in 2012 (p=0.327). The sites of approach in 2018 and 2012 were the internal jugular in 42 (22%) and 54 (27%), subclavian in 52 (28%) and 128 (65%), brachial (PICC) in 89 (48%) and 14 (7%), and femoral in 4 (2%) and 2 (1%), respectively (p<0.001). Conclusion USG has become commonplace since its introduction. The landmark-based subclavian approach was largely replaced by PICC with USG in 2018. USG and PICC can help improve success rates and safety profiles.

Safety, Efficacy, and Patient Satisfaction with Initial Peripherally Inserted Central Catheters Compared with Usual Intravenous Access in Terminally Ill Cancer Patients: A Randomized Phase II Study

Purpose

The purpose of this study was to investigate whether routine insertion of peripherally inserted central catheter (PICC) at admission to a hospice-palliative care (HPC) unit is acceptable in terms of safety and efficacy and whether it results in superior patient satisfaction compared to usual intravenous (IV) access.

Materials and Methods

Terminally ill cancer patients were randomly assigned to two arms: routine PICC access and usual IV access arm. The primary endpoint was IV maintenance success rate, defined as the rate of functional IV maintenance until the intended time (discharge, transfer, or death).

Results

A total of 66 terminally ill cancer patients were enrolled and randomized to study arms. Among them, 57 patients (routine PICC, 29; usual IV, 28) were analyzed. In the routine PICC arm, mean time to PICC was 0.84 days (range, 0 to 3 days), 27 patients maintained PICC with function until the intended time. In the usual IV arm, 11 patients maintained peripheral IV access until the intended time, and 15 patients underwent PICC insertion. The IV maintenance success rate in the routine PICC arm (27/29, 93.1%) was similar to that in the usual IV arm (26/28, 92.8%, p=0.958). Patient satisfaction at day 5 was better in the routine PICC arm (97%, ‘a little comfort’ or ‘much comfort’) compared with the usual IV arm (21%) (p < 0.001).

Conclusion

Routine PICC insertion in terminally ill cancer patients was comparable in safety and efficacy and resulted in superior satisfaction compared with usual IV access. Thus, routine PICC insertion could be considered at admission to the HPC unit.

OBJECTIVE ASSESSMENT METRICS FOR CENTRAL LINE SIMULATORS: AN EXPLORATION OF CAUSAL FACTORS

The Dynamic Haptic Robotic Trainer (DHRT) was developed to minimize the up to 39% of adverse effects experienced by patients during Central Venous Catheterization (CVC) by standardizing CVC training, and provide automated assessments of performance. Specifically, this system was developed to replace manikin trainers that only simulate one patient anatomy and require a trained preceptor to evaluate the trainees' performance. While the DHRT system provides automated feedback, the utility of this system with real-world scenarios and expertise has yet to be thoroughly investigated. Thus, the current study was developed to determine the validity of the current objective assessment metrics incorporated in the DHRT system through expert interviews. The main findings from this study are that experts do agree on perceptions of patient case difficulty, and that characterizations of patient case difficulty is based on anatomical characteristics, multiple needle insertions, and prior catheterization.

Precisely Structured Nitric-Oxide-Releasing Copolymer Brush Defeats Broad-Spectrum Catheter-Associated Biofilm Infections In Vivo

Gram-negative bacteria cannot be easily eradicated by antibiotics and are a major source of recalcitrant infections of indwelling medical devices. Among various device-associated infections, intravascular catheter infection is a leading cause of mortality. Prior approaches to surface modification, such as antibiotics impregnation, hydrophilization, unstructured NO-releasing, etc., have failed to achieve adequate infection-resistant coatings. We report a precision-structured diblock copolymer brush (H(N)-b-S) composed of a surface antifouling block of poly(sulfobetaine methacrylate) (S) and a subsurface bactericidal block (H(N)) of nitric-oxide-emitting functionalized poly(hydroxyethyl methacrylate) (H) covalently grafted from the inner and outer surfaces of a polyurethane catheter. The block copolymer architecture of the coating is important for achieving good broad-spectrum anti-biofilm activity with good biocompatibility and low fouling. The coating procedure is scalable to clinically useful catheter lengths. Only the block copolymer brush coating ((H(N)-b-S)) shows unprecedented, above 99.99%, in vitro biofilm inhibition of Gram-positive and Gram-negative bacteria, 100-fold better than previous coatings. It has negligible toxicity toward mammalian cells and excellent blood compatibility. In a murine subcutaneous infection model, it achieves >99.99% biofilm reduction of Gram-positive and Gram-negative bacteria compared with <90% for silver catheter, while in a porcine central venous catheter infection model, it achieves >99.99% reduction of MRSA with 5-day implantation. This precision coating is readily applicable for long-term biofilm-resistant and blood-compatible copolymer coatings covalently grafted from a wide range of medical devices.

[Complications and success rates of subclavian vein catheterization depending on experience]

BACKGROUND

The infraclavicular puncture of the subclavian vein is a standard procedure for anesthetists. Meanwhile the literature and recommendations are clear and the use of real-time ultrasound guidance is the standard procedure; however, anesthetists will always get into special circumstances were they have to use the landmark technique, so this competence must be preserved. Feared complications of infraclavicular subclavian vein puncture are pneumothorax and arterial puncture. Up to now there is no clear learning curve for the infraclavicular subclavian vein puncture in the landmark technique performed by anesthetists.

OBJECTIVE

The aim of this study was to examine the influence of the puncture experience on the success rate and mechanical complications, such as pneumothorax and arterial puncture in patients who received an infraclavicular subclavian vein puncture with the landmark technique. Three levels of experience were defined for comparison: inexperienced 0-20 punctures, moderately experienced 21-50 and experienced over 50 punctures.

MATERIAL AND METHODS

Post hoc analysis of a previously published noninferiority study to examine the influence of ventilation on the pneumothorax rate in the subclavian vein puncture using the landmark technique. This analysis included 1021 anesthetized patients who were included in the original study between August 2014 and October 2017. Demographic data as well as the number of puncture attempts, puncture success, the overall rate of mechanical complications, pneumothorax rate and arterial puncture rates were calculated.

RESULTS

The overall rate of mechanical complications (pneumothorax + arterial puncture) was significantly higher in the inexperienced group (0-21) compared to the experienced group (>50, 15% vs. 8.5%, respectively, p = 0.023). This resulted in an odds ratio of 0.52 (confidence interval, CI: 0.32-0.85, p = 0.027). Likewise, the rate of puncture attempts in the group of inexperienced (0-20) with 1.85 ± 1.12 was significantly higher than in the group of experienced (>50, 1.58 ± 0.99, p = 0.004) and resulted in an odds ratio of 0.59 (CI: 0.31-0.96, p = 0.028). Although the puncture attempts of the moderately experienced (21-50) compared to the inexperienced (0-20) was not significant lower, we found an odds ratio of 0.69 (CI: 0.48-0.99, p = 0.042). The rate of successful puncture was 95.1% in the experienced group versus 89.3% in the inexperienced group (p = 0.001), which resulted in an odds ratio of 2.35 (CI: 1.28-4.31, p = 0.018). When viewed individually, no significant differences were found for pneumothorax and arterial puncture.

CONCLUSION

In this post hoc analysis of the puncture of the subclavian vein using the landmark technique, we found a significant reduction of puncture attempts and overall mechanical complications. At least 50 punctures seem to be necessary to achieve the end of the learning curve; however, the landmark technique should only be used under special circumstances, when real-time ultrasound is not available. Anesthetists who want to complete their repertoire and learn the landmark technique should always perform a static ultrasound examination before starting the puncture in order to reduce complications due to anatomical variations or thrombosis.

Comparison of Right Ventricular Function Between Three-Dimensional Transesophageal Echocardiography and Pulmonary Artery Catheter

OBJECTIVE

This study aimed to compare measurements of right ventricular function using three-dimensional transesophageal echocardiography (3D TEE), and pulmonary artery catheters (PACs) in patients undergoing cardiac surgery. The authors examined the practicality of using the 3D TEE.

DESIGN

Prospective observational.

SETTING

Cardiac operating room at a single university hospital.

PARTICIPANTS

All adult patients undergoing elective cardiac surgery at a single tertiary care university hospital over two years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), stroke volume (SV), and right ventricular ejection fraction (RVEF) were measured with both 3D TEE and PACs. Assessments were performed using correlation coefficients, paired t tests, and Bland-Altman plots. Thirty-one patients participated in this study. Each measurement showed good agreement. RVEDV and RVESV were slightly lower on 3D TEE than on PAC (205.9 mL v 220.2 mL, p = 0.0018; 143.0 mL v 155.5 mL, p = 0.0143, respectively), whereas no significant differences were observed for SV and RVEF (31.0% v 31.1%, p = 0.0569; 61.6 mL v 66.9 mL, p = 0.92, respectively). Linear regression analysis showed high correlation between 3D TEE and PAC for RVEDV (r = 0.87) and RVESV (r = 0.81), and moderate correlation for SV (r = 0.67) and RVEF (r = 0.67). In the Bland-Altman plot, most patients were within the 95% limits of the agreement throughout all measurements.

CONCLUSION

A high correlation was found between measurements made with a PAC and with 3D TEE in the assessment of right ventricular function. Three-dimensional TEE would be a potential alternative to PAC for assessment of right ventricular function during intraoperative periods.

Feasibility and Safety of Peripheral Intravenous Administration of Vasopressor Agents in Resource-limited Settings

Background

Vasopressors are conventionally administered through a central venous catheter (CVC) and not through a peripheral venous catheter (PVC) since the latter is believed to be associated with increased risk of extravasation. Placement of a CVC requires suitably trained personnel to be on hand, and in resource-limited settings, this requirement may delay placement. Because of this and in cases where suitably trained personnel are not immediately available, some clinicians may be prompted to utilise a PVC for infusing vasopressors. The objective of this study is to assess the feasibility and safety of vasopressors administered through a PVC.

Materials and methods

Patients who received vasopressors through a PVC for more than one hour were included in a single centre, consecutive patient observational study. Patients with a CVC at the time of initiation of vasopressors were excluded. Data regarding the size, location of PVCs, dose, duration and number of vasopressors infused were recorded. The decision to place CVC was left to the discretion of the treating physician. Extravasation incidents, severity and management of such events were recorded.

Results

One hundred twenty-two patients age 55(4) years [mean (SD)] were included in the study. The commonest PVC was of 18G calibre (57%), and the most common site of placement was the external jugular vein (36.5%). Noradrenaline was the most common vasopressor used at a dose of 10.6 (7) mcg/min [mean (SD)] and the median duration of nine hours (IQR: 6-14). CVC was placed most commonly due to an increasing dose of vasopressors after 4.5(4) hours [mean (SD)]. Grade 2 Extravasation injury occurred in one patient after prolonged infusion of fifty-two hours, through a small calibre (20G) PVC, which was managed conservatively without any sequelae.

Conclusion

Vasopressors infused through a PVC of 18G or larger calibre into the external jugular, or a forearm vein is feasible and safe. Clinicians need to balance the safety of peripheral vasopressor infusion with the additional costs and complications associated with CVC in resource-limited settings.

Ultrasound guidance for femoral venous access in electrophysiology procedures-systematic review and meta-analysis

PURPOSE

The most common complications of electrophysiology (EP) procedures are related to vascular access. Our study aims to conduct a meta-analysis comparing ultrasound (US)-guided vs. palpation-based technique for femoral venous access in EP procedures.

METHODS

Electronic databases were searched and systematically reviewed for studies comparing femoral vein puncture with/without US in EP procedures. The primary outcome was the rate of major vascular complications; secondary outcomes were minor vascular complications, inadvertent artery puncture, postprocedural groin pain, and puncture time. Predefined subgroup analysis was conducted separately for patients undergoing pulmonary vein isolation procedure (PVI). A random-effects model was used to derive risk ratios (RR) with 95% confidence interval (CI).

RESULTS

Nine studies involving 8232 patients met our inclusion criteria. Compared with the standard technique, the use of US reduced major vascular complications (from 2.01 to 0.71%, p < 0.0001). The rate of minor vascular complications (RR = 0.30, 95% CI, 0.14-0.62, p = 0.001) and inadvertent artery puncture were lower with US-guided puncture (RR = 0.31, 95% CI, 0.17-0.58, p = 0.0003). Puncture time was shorter (mean difference = - 92.1 s, 95% CI, - 142.12 - - 42.07 s, p = 0.0003) and postprocedural groin pain was less frequent (RR = 0.57, 95% CI, 0.41-0.79, p = 0.0008) in the US group. Subgroup analysis of patients undergoing PVI also showed significant reduction of major vascular complications (RR = 0.27, 95% CI, 0.12-0.64, p = 0.003) and inadvertent artery puncture (RR = 0.35, 95% CI, 0.21-0.59, p < 0.0001).

CONCLUSION

Real-time US-guidance of femoral vein puncture in EP procedures is beneficial: it reduces major and minor vascular complications, inadvertent artery puncture, postprocedural groin pain, and puncture time.

Gastrointestinal stromal tumor metastasis at the site of a totally implantable venous access port insertion: A rare case report

BACKGROUND

The totally implantable venous access port (TIVAP) is an important device in patients for injecting blood products, parenteral nutrition or antineoplastic chemotherapy. Metastatic spread at the site of the insertion of a TIVAP is extremely rare.

CASE SUMMARY

We report the case of 33-year-old male with advanced gastrointestinal stromal tumor (GIST) who underwent radical tumor resection after neoadjuvant imatinib therapy. However, a solitary GIST metastasis at the site of a TIVAP insertion developed during adjuvant imatinib treatment. Mutational analysis showed secondary mutation in KIT exon 13 (V564A), which is resistant to imatinib treatment. To our knowledge, this is the first case report of a patient with advanced GIST developing GIST metastasis at the site of a TIVAP insertion.

CONCLUSION

This case highlights that when a patient with advanced, high metastatic GIST requires TIVAP insertion, we should realize that there is a risk of developing tumor metastasis at the site of a TIVAP insertion.

Clinical Interrogation of Mandatory Insertion of Central Venous Catheter for Clipping Surgery of Unruptured Intracranial Aneurysm: A Propensity Score Matched Study

BACKGROUND AND OBJECTIVE

Microsurgical clipping, along with endovascular treatment, has evolved in the treatment of unruptured intracranial aneurysms (UIA), and these developments have resulted in a reduction of the complication rate. We discuss the need for a central venous catheter (CVC) insertion as an anesthetic preparation for microsurgical clipping.

METHODS

Between January 2019 and September 2019, 722 patients with UIA were treated at our institution. We excluded patients with a history of endovascular treatment or bypass surgery, recurrent aneurysms after coil embolization, brain tumors, or subarachnoid hemorrhages. A total of 272 patients were enrolled. Eighty-four patients underwent CVC insertion, and 188 patients underwent clipping surgery without CVC insertion. Outcome-related factors were compared between the 2 groups. We performed propensity score matching of the 2 groups to increase comparability.

RESULTS

There were no significant differences in outcome, sex, aneurysm location, aneurysm multiplicity, aneurysm size, or comorbid disease between the 2 groups. The mean age at the time of surgery was higher in the non-CVC insertion group than in the CVC insertion group. There were no meaningful differences in primary outcomes, including premature rupture and intraoperative motor evoked potential/somatosensory evoked potential change, and secondary outcomes, including estimated blood loss, duration of intensive care unit stay, duration of hospitalization, and Glasgow Outcome Scale score at discharge.

CONCLUSIONS

CVC insertion for clipping surgery for UIA is not mandatory. Considering the possible complications associated with CVCs, we cautiously suggest aneurysm surgery with CVC insertion in patients with serious medical comorbidities, aneurysm sizes >10 mm, and difficult proximal parent artery control.