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Green ML, Kim Y, Hendel S, Groombridge CJ, Fitzgerald M. Review article: Feasibility of brachiocephalic vein central venous access for the resuscitation of shocked adult trauma patients: A literature review. Emerg Med Australas 2024; 36:6-12. [PMID: 37932025 DOI: 10.1111/1742-6723.14332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/09/2023] [Indexed: 11/08/2023]
Abstract
Venous access is a key component of managing haemorrhagic shock. Obtaining intravenous access in trauma patients is challenging due to circulatory collapse in shock. This literature review examines the feasibility of direct puncture and cannulation of the brachiocephalic veins (BCVs) for intravenous access in shocked adult trauma patients. Three literature searches were conducted. OVID Medline was searched for articles on the use of the BCVs for venous access in adults and on the BCVs in shock. A third systematic search of OVID Medline, OVID Embase and Cochrane Library was conducted on the use of the BCVs for access in shocked trauma patients. After full-text review, 18 studies were selected for inclusion for the search on the use of the BCVs for access in adults. No studies met the inclusion criteria for the search on the BCVs in shock and BCV access in shocked trauma patients. The BCVs are currently used for central venous access, haemodialysis and totally implantable venous access devices (TIVADs) in adults. There is a preference for the right BCV (RBCV) over the left as the RBCV is more superficial, straighter, larger, has less anatomical variation and avoids the risk of thoracic duct puncture. The BCVs appear to be stabilised in shock by surrounding bony structures. The BCVs may provide a site for initial, rapid access in trauma resuscitation. Further research is required to determine if the BCVs collapse in shock and if venous access using the BCVs is feasible in a trauma resuscitation setting.
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Affiliation(s)
- Madeline L Green
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Yesul Kim
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Simon Hendel
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
- Trauma Service, Alfred Health, Melbourne, Victoria, Australia
| | - Christopher J Groombridge
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
- Trauma Service, Alfred Health, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
- Trauma Service, Alfred Health, Melbourne, Victoria, Australia
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Jatczak L, Puton RC, Proença AJL, Rubin LC, Borges LB, Saleh JN, Corrêa MP. Complications of central venous catheterization at a vascular surgery service in a teaching hospital: a prospective cohort study. J Vasc Bras 2023; 22:e20230070. [PMID: 37790889 PMCID: PMC10545227 DOI: 10.1590/1677-5449.202300702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/12/2023] [Indexed: 10/05/2023] Open
Abstract
Background Central venous catheters are essential for management of hospitalized patients, but their insertion is subject to complications that can make them unusable and/or cause patient morbidity. There are few data on the incidence of these complications and the variables associated with these outcomes in Brazil. Objectives To determine the incidence of mechanical complications and failures of short stay central venous catheters fitted by the vascular surgery service at a teaching hospital and identify variables associated with their occurrence. Methods This was a prospective cohort of 73 attempts to fit patients with a central venous catheter performed by the vascular surgery service at a teaching hospital from July to October of 2022. Results Mechanical complications occurred in 12 cannulation attempts (16.44%) and there were 10 failures (13.70%). The factors associated with mechanical complications were less experienced operators (p < 0.001), less specialized operators (p = 0.014), a failed attempt prior to requesting help from the vascular surgery service (p = 0.008), and presence of at least two criteria for difficulty (p = 0.007). Conclusions The local incidence of mechanical complications and central venous cannulation failures was similar to rates described in the international literature, but higher than rates in other Brazilian studies. The results suggest that the degree of experience of the person fitting the catheter, history of a failed prior attempt, and presence of at least two criteria for difficulty identified before the procedure were associated with worse outcomes.
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Affiliation(s)
| | - Renan Camargo Puton
- Instituto Vascular de Passo Fundo - INVASC, Passo Fundo, RS, Brasil.
- Hospital de Clínicas de Passo Fundo - HCPF, Passo Fundo, RS, Brasil.
| | | | | | - Luiza Brum Borges
- Instituto Vascular de Passo Fundo - INVASC, Passo Fundo, RS, Brasil.
- Hospital de Clínicas de Passo Fundo - HCPF, Passo Fundo, RS, Brasil.
| | - Jaber Nashat Saleh
- Instituto Vascular de Passo Fundo - INVASC, Passo Fundo, RS, Brasil.
- Hospital de Clínicas de Passo Fundo - HCPF, Passo Fundo, RS, Brasil.
- Universidade de Passo Fundo - UPF, Passo Fundo, RS, Brasil.
| | - Mateus Picada Corrêa
- Faculdade Meridional - IMED, Passo Fundo, RS, Brasil.
- Instituto Vascular de Passo Fundo - INVASC, Passo Fundo, RS, Brasil.
- Hospital de Clínicas de Passo Fundo - HCPF, Passo Fundo, RS, Brasil.
- Universidade de Passo Fundo - UPF, Passo Fundo, RS, Brasil.
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3
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Powell SM, Faust AC, George S, Townsend R, Eubank D, Kim R. Effect of Peripherally Infused Norepinephrine on Reducing Central Venous Catheter Utilization. JOURNAL OF INFUSION NURSING 2023; 46:210-216. [PMID: 37406335 DOI: 10.1097/nan.0000000000000508] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
The purpose of this retrospective study was to evaluate the impact of peripherally administered norepinephrine on avoiding central venous catheter insertion while maintaining safety of the infusion. An institutional guideline allows peripheral infusion of norepinephrine via dedicated, 16- to 20-gauge, mid-to-upper arm intravenous (IV) catheters for up to 24 hours. The primary outcome was the need for central venous access in patients initially started on peripherally infused norepinephrine. A total of 124 patients were evaluated (98 initially on peripherally infused norepinephrine vs 26 with central catheter only administration). Thirty-six (37%) of the 98 patients who were started on peripheral norepinephrine avoided the need for central catheter placement, which was associated with $8,900 in direct supply cost avoidance. Eighty (82%) of the 98 patients who started peripherally infused norepinephrine required the vasopressor for ≤12 hours. No extravasation or local complications were observed in any of the 124 patients, regardless of site of infusion. Administration of norepinephrine via a dedicated peripheral IV site appears safe and may lead to a reduction in the need for subsequent central venous access. To achieve timely resuscitation goals, as well as to minimize complications associated with central access, initial peripheral administration should be considered for all patients.
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Affiliation(s)
- Sara M Powell
- Department of Pharmacy (Drs Powell, Faust, and George) and Infusion Support Team, Department of Nursing (Mr Townsend and Ms Eubank), Texas Health Presbyterian Hospital Dallas, Dallas, Texas; Sound Physician Group, Pulmonary/Critical Care Medicine, Dallas, Texas (Dr Kim)
- Sara M. Powell, PharmD, MS, is the current postgraduate year 2 Critical Care pharmacy resident at Texas Health Dallas, where she also completed her postgraduate year 1 Pharmacy Practice residency. She received her Master of Science degree in 2016 and Doctor of Pharmacy degree in 2021 from Texas Tech University Health Sciences Center in Lubbock, Texas. Dr Powell has research and practice interests in anticoagulant reversal, septic shock management, antimicrobial stewardship, and trauma. Andrew C. Faust, PharmD, BCPS, is the current medical intensive care unit clinical pharmacy specialist at Texas Health Dallas and has been in this role since 2011. He graduated pharmacy school from the University of Texas at Austin in 2009 and followed that with a postgraduate year 1 Pharmacy Practice residency at University Health in San Antonio, Texas, and a postgraduate year 2 Critical Care pharmacy residency at Methodist University Hospital in Memphis, Tennessee. Dr Faust has published multiple articles in the areas of critical care, anticoagulation, and infectious diseases and has interests in management of sepsis/shock, rationale antimicrobial use in critically ill patients, and sedation/analgesia management. Stephy George, PharmD, BCCCP, is the current emergency department (ED)/trauma clinical pharmacy specialist. She graduated from University of Houston College of Pharmacy in 2013 and completed her pharmacotherapy postgraduate year 1 at Methodist Hospital in San Antonio and Critical Care and postgraduate year 2 at North Texas VA/Texas Tech Health Science Center in Dallas before starting her career as a critical care pharmacy specialist in 2016. Her clinical areas of interest are multimodal pain management, ICU antimicrobial stewardship, and management of agitation in the ED. Richard Townsend, RN, has worked as a vascular access nurse at Texas Health Dallas since March of 2020. He graduated from nursing school in 2006 and has prior experience in intensive care nursing, emergency nursing as a medicine and trauma nurse, and in the cardiac catheterization laboratory. Darla Eubank, RN, received her Bachelor of Science in Nursing from Abilene Christian University in 1996. After graduation, she worked as a telemetry nurse, cardiac catheterization laboratory nurse, and progressive cardiac care unit charge nurse. She has been an infusion support nurse at Texas Health Dallas since 2003 and now serves as the charge nurse for the vascular access team. Ms Eubank has received an Impact Award from Texas Christian University for her work on an evidence-based project focused on midline use in difficult access patients. Richard Kim, MD, is a board-certified internal, pulmonary, and critical care medicine physician in Dallas, Texas. He completed internal medicine residency and a pulmonary and critical care medicine fellowship at the University of Louisville in 2020. He has particular interest in sepsis, point-of-care ultrasound, and pulmonary hypertension
| | - Andrew C Faust
- Department of Pharmacy (Drs Powell, Faust, and George) and Infusion Support Team, Department of Nursing (Mr Townsend and Ms Eubank), Texas Health Presbyterian Hospital Dallas, Dallas, Texas; Sound Physician Group, Pulmonary/Critical Care Medicine, Dallas, Texas (Dr Kim)
- Sara M. Powell, PharmD, MS, is the current postgraduate year 2 Critical Care pharmacy resident at Texas Health Dallas, where she also completed her postgraduate year 1 Pharmacy Practice residency. She received her Master of Science degree in 2016 and Doctor of Pharmacy degree in 2021 from Texas Tech University Health Sciences Center in Lubbock, Texas. Dr Powell has research and practice interests in anticoagulant reversal, septic shock management, antimicrobial stewardship, and trauma. Andrew C. Faust, PharmD, BCPS, is the current medical intensive care unit clinical pharmacy specialist at Texas Health Dallas and has been in this role since 2011. He graduated pharmacy school from the University of Texas at Austin in 2009 and followed that with a postgraduate year 1 Pharmacy Practice residency at University Health in San Antonio, Texas, and a postgraduate year 2 Critical Care pharmacy residency at Methodist University Hospital in Memphis, Tennessee. Dr Faust has published multiple articles in the areas of critical care, anticoagulation, and infectious diseases and has interests in management of sepsis/shock, rationale antimicrobial use in critically ill patients, and sedation/analgesia management. Stephy George, PharmD, BCCCP, is the current emergency department (ED)/trauma clinical pharmacy specialist. She graduated from University of Houston College of Pharmacy in 2013 and completed her pharmacotherapy postgraduate year 1 at Methodist Hospital in San Antonio and Critical Care and postgraduate year 2 at North Texas VA/Texas Tech Health Science Center in Dallas before starting her career as a critical care pharmacy specialist in 2016. Her clinical areas of interest are multimodal pain management, ICU antimicrobial stewardship, and management of agitation in the ED. Richard Townsend, RN, has worked as a vascular access nurse at Texas Health Dallas since March of 2020. He graduated from nursing school in 2006 and has prior experience in intensive care nursing, emergency nursing as a medicine and trauma nurse, and in the cardiac catheterization laboratory. Darla Eubank, RN, received her Bachelor of Science in Nursing from Abilene Christian University in 1996. After graduation, she worked as a telemetry nurse, cardiac catheterization laboratory nurse, and progressive cardiac care unit charge nurse. She has been an infusion support nurse at Texas Health Dallas since 2003 and now serves as the charge nurse for the vascular access team. Ms Eubank has received an Impact Award from Texas Christian University for her work on an evidence-based project focused on midline use in difficult access patients. Richard Kim, MD, is a board-certified internal, pulmonary, and critical care medicine physician in Dallas, Texas. He completed internal medicine residency and a pulmonary and critical care medicine fellowship at the University of Louisville in 2020. He has particular interest in sepsis, point-of-care ultrasound, and pulmonary hypertension
| | - Stephy George
- Department of Pharmacy (Drs Powell, Faust, and George) and Infusion Support Team, Department of Nursing (Mr Townsend and Ms Eubank), Texas Health Presbyterian Hospital Dallas, Dallas, Texas; Sound Physician Group, Pulmonary/Critical Care Medicine, Dallas, Texas (Dr Kim)
- Sara M. Powell, PharmD, MS, is the current postgraduate year 2 Critical Care pharmacy resident at Texas Health Dallas, where she also completed her postgraduate year 1 Pharmacy Practice residency. She received her Master of Science degree in 2016 and Doctor of Pharmacy degree in 2021 from Texas Tech University Health Sciences Center in Lubbock, Texas. Dr Powell has research and practice interests in anticoagulant reversal, septic shock management, antimicrobial stewardship, and trauma. Andrew C. Faust, PharmD, BCPS, is the current medical intensive care unit clinical pharmacy specialist at Texas Health Dallas and has been in this role since 2011. He graduated pharmacy school from the University of Texas at Austin in 2009 and followed that with a postgraduate year 1 Pharmacy Practice residency at University Health in San Antonio, Texas, and a postgraduate year 2 Critical Care pharmacy residency at Methodist University Hospital in Memphis, Tennessee. Dr Faust has published multiple articles in the areas of critical care, anticoagulation, and infectious diseases and has interests in management of sepsis/shock, rationale antimicrobial use in critically ill patients, and sedation/analgesia management. Stephy George, PharmD, BCCCP, is the current emergency department (ED)/trauma clinical pharmacy specialist. She graduated from University of Houston College of Pharmacy in 2013 and completed her pharmacotherapy postgraduate year 1 at Methodist Hospital in San Antonio and Critical Care and postgraduate year 2 at North Texas VA/Texas Tech Health Science Center in Dallas before starting her career as a critical care pharmacy specialist in 2016. Her clinical areas of interest are multimodal pain management, ICU antimicrobial stewardship, and management of agitation in the ED. Richard Townsend, RN, has worked as a vascular access nurse at Texas Health Dallas since March of 2020. He graduated from nursing school in 2006 and has prior experience in intensive care nursing, emergency nursing as a medicine and trauma nurse, and in the cardiac catheterization laboratory. Darla Eubank, RN, received her Bachelor of Science in Nursing from Abilene Christian University in 1996. After graduation, she worked as a telemetry nurse, cardiac catheterization laboratory nurse, and progressive cardiac care unit charge nurse. She has been an infusion support nurse at Texas Health Dallas since 2003 and now serves as the charge nurse for the vascular access team. Ms Eubank has received an Impact Award from Texas Christian University for her work on an evidence-based project focused on midline use in difficult access patients. Richard Kim, MD, is a board-certified internal, pulmonary, and critical care medicine physician in Dallas, Texas. He completed internal medicine residency and a pulmonary and critical care medicine fellowship at the University of Louisville in 2020. He has particular interest in sepsis, point-of-care ultrasound, and pulmonary hypertension
| | - Richard Townsend
- Department of Pharmacy (Drs Powell, Faust, and George) and Infusion Support Team, Department of Nursing (Mr Townsend and Ms Eubank), Texas Health Presbyterian Hospital Dallas, Dallas, Texas; Sound Physician Group, Pulmonary/Critical Care Medicine, Dallas, Texas (Dr Kim)
- Sara M. Powell, PharmD, MS, is the current postgraduate year 2 Critical Care pharmacy resident at Texas Health Dallas, where she also completed her postgraduate year 1 Pharmacy Practice residency. She received her Master of Science degree in 2016 and Doctor of Pharmacy degree in 2021 from Texas Tech University Health Sciences Center in Lubbock, Texas. Dr Powell has research and practice interests in anticoagulant reversal, septic shock management, antimicrobial stewardship, and trauma. Andrew C. Faust, PharmD, BCPS, is the current medical intensive care unit clinical pharmacy specialist at Texas Health Dallas and has been in this role since 2011. He graduated pharmacy school from the University of Texas at Austin in 2009 and followed that with a postgraduate year 1 Pharmacy Practice residency at University Health in San Antonio, Texas, and a postgraduate year 2 Critical Care pharmacy residency at Methodist University Hospital in Memphis, Tennessee. Dr Faust has published multiple articles in the areas of critical care, anticoagulation, and infectious diseases and has interests in management of sepsis/shock, rationale antimicrobial use in critically ill patients, and sedation/analgesia management. Stephy George, PharmD, BCCCP, is the current emergency department (ED)/trauma clinical pharmacy specialist. She graduated from University of Houston College of Pharmacy in 2013 and completed her pharmacotherapy postgraduate year 1 at Methodist Hospital in San Antonio and Critical Care and postgraduate year 2 at North Texas VA/Texas Tech Health Science Center in Dallas before starting her career as a critical care pharmacy specialist in 2016. Her clinical areas of interest are multimodal pain management, ICU antimicrobial stewardship, and management of agitation in the ED. Richard Townsend, RN, has worked as a vascular access nurse at Texas Health Dallas since March of 2020. He graduated from nursing school in 2006 and has prior experience in intensive care nursing, emergency nursing as a medicine and trauma nurse, and in the cardiac catheterization laboratory. Darla Eubank, RN, received her Bachelor of Science in Nursing from Abilene Christian University in 1996. After graduation, she worked as a telemetry nurse, cardiac catheterization laboratory nurse, and progressive cardiac care unit charge nurse. She has been an infusion support nurse at Texas Health Dallas since 2003 and now serves as the charge nurse for the vascular access team. Ms Eubank has received an Impact Award from Texas Christian University for her work on an evidence-based project focused on midline use in difficult access patients. Richard Kim, MD, is a board-certified internal, pulmonary, and critical care medicine physician in Dallas, Texas. He completed internal medicine residency and a pulmonary and critical care medicine fellowship at the University of Louisville in 2020. He has particular interest in sepsis, point-of-care ultrasound, and pulmonary hypertension
| | - Darla Eubank
- Department of Pharmacy (Drs Powell, Faust, and George) and Infusion Support Team, Department of Nursing (Mr Townsend and Ms Eubank), Texas Health Presbyterian Hospital Dallas, Dallas, Texas; Sound Physician Group, Pulmonary/Critical Care Medicine, Dallas, Texas (Dr Kim)
- Sara M. Powell, PharmD, MS, is the current postgraduate year 2 Critical Care pharmacy resident at Texas Health Dallas, where she also completed her postgraduate year 1 Pharmacy Practice residency. She received her Master of Science degree in 2016 and Doctor of Pharmacy degree in 2021 from Texas Tech University Health Sciences Center in Lubbock, Texas. Dr Powell has research and practice interests in anticoagulant reversal, septic shock management, antimicrobial stewardship, and trauma. Andrew C. Faust, PharmD, BCPS, is the current medical intensive care unit clinical pharmacy specialist at Texas Health Dallas and has been in this role since 2011. He graduated pharmacy school from the University of Texas at Austin in 2009 and followed that with a postgraduate year 1 Pharmacy Practice residency at University Health in San Antonio, Texas, and a postgraduate year 2 Critical Care pharmacy residency at Methodist University Hospital in Memphis, Tennessee. Dr Faust has published multiple articles in the areas of critical care, anticoagulation, and infectious diseases and has interests in management of sepsis/shock, rationale antimicrobial use in critically ill patients, and sedation/analgesia management. Stephy George, PharmD, BCCCP, is the current emergency department (ED)/trauma clinical pharmacy specialist. She graduated from University of Houston College of Pharmacy in 2013 and completed her pharmacotherapy postgraduate year 1 at Methodist Hospital in San Antonio and Critical Care and postgraduate year 2 at North Texas VA/Texas Tech Health Science Center in Dallas before starting her career as a critical care pharmacy specialist in 2016. Her clinical areas of interest are multimodal pain management, ICU antimicrobial stewardship, and management of agitation in the ED. Richard Townsend, RN, has worked as a vascular access nurse at Texas Health Dallas since March of 2020. He graduated from nursing school in 2006 and has prior experience in intensive care nursing, emergency nursing as a medicine and trauma nurse, and in the cardiac catheterization laboratory. Darla Eubank, RN, received her Bachelor of Science in Nursing from Abilene Christian University in 1996. After graduation, she worked as a telemetry nurse, cardiac catheterization laboratory nurse, and progressive cardiac care unit charge nurse. She has been an infusion support nurse at Texas Health Dallas since 2003 and now serves as the charge nurse for the vascular access team. Ms Eubank has received an Impact Award from Texas Christian University for her work on an evidence-based project focused on midline use in difficult access patients. Richard Kim, MD, is a board-certified internal, pulmonary, and critical care medicine physician in Dallas, Texas. He completed internal medicine residency and a pulmonary and critical care medicine fellowship at the University of Louisville in 2020. He has particular interest in sepsis, point-of-care ultrasound, and pulmonary hypertension
| | - Richard Kim
- Department of Pharmacy (Drs Powell, Faust, and George) and Infusion Support Team, Department of Nursing (Mr Townsend and Ms Eubank), Texas Health Presbyterian Hospital Dallas, Dallas, Texas; Sound Physician Group, Pulmonary/Critical Care Medicine, Dallas, Texas (Dr Kim)
- Sara M. Powell, PharmD, MS, is the current postgraduate year 2 Critical Care pharmacy resident at Texas Health Dallas, where she also completed her postgraduate year 1 Pharmacy Practice residency. She received her Master of Science degree in 2016 and Doctor of Pharmacy degree in 2021 from Texas Tech University Health Sciences Center in Lubbock, Texas. Dr Powell has research and practice interests in anticoagulant reversal, septic shock management, antimicrobial stewardship, and trauma. Andrew C. Faust, PharmD, BCPS, is the current medical intensive care unit clinical pharmacy specialist at Texas Health Dallas and has been in this role since 2011. He graduated pharmacy school from the University of Texas at Austin in 2009 and followed that with a postgraduate year 1 Pharmacy Practice residency at University Health in San Antonio, Texas, and a postgraduate year 2 Critical Care pharmacy residency at Methodist University Hospital in Memphis, Tennessee. Dr Faust has published multiple articles in the areas of critical care, anticoagulation, and infectious diseases and has interests in management of sepsis/shock, rationale antimicrobial use in critically ill patients, and sedation/analgesia management. Stephy George, PharmD, BCCCP, is the current emergency department (ED)/trauma clinical pharmacy specialist. She graduated from University of Houston College of Pharmacy in 2013 and completed her pharmacotherapy postgraduate year 1 at Methodist Hospital in San Antonio and Critical Care and postgraduate year 2 at North Texas VA/Texas Tech Health Science Center in Dallas before starting her career as a critical care pharmacy specialist in 2016. Her clinical areas of interest are multimodal pain management, ICU antimicrobial stewardship, and management of agitation in the ED. Richard Townsend, RN, has worked as a vascular access nurse at Texas Health Dallas since March of 2020. He graduated from nursing school in 2006 and has prior experience in intensive care nursing, emergency nursing as a medicine and trauma nurse, and in the cardiac catheterization laboratory. Darla Eubank, RN, received her Bachelor of Science in Nursing from Abilene Christian University in 1996. After graduation, she worked as a telemetry nurse, cardiac catheterization laboratory nurse, and progressive cardiac care unit charge nurse. She has been an infusion support nurse at Texas Health Dallas since 2003 and now serves as the charge nurse for the vascular access team. Ms Eubank has received an Impact Award from Texas Christian University for her work on an evidence-based project focused on midline use in difficult access patients. Richard Kim, MD, is a board-certified internal, pulmonary, and critical care medicine physician in Dallas, Texas. He completed internal medicine residency and a pulmonary and critical care medicine fellowship at the University of Louisville in 2020. He has particular interest in sepsis, point-of-care ultrasound, and pulmonary hypertension
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Iankovitch A, Ledley JS, Almabrouk T, Al-Jaberi N, Coey J. Anatomical variations of the internal jugular vein in the context of central line placement: A visual approach to data processing. Clin Anat 2023; 36:172-177. [PMID: 35869858 DOI: 10.1002/ca.23939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/08/2022]
Abstract
Central line placement in the internal jugular vein (IJV) can result in complications. Previous studies that examined variations in geometric anatomical parameters in pediatric populations have reduced these risks in children. The aim of this study was to establish possible anatomical variations to improve central line placement in the adult population and demonstrate the use of a correlation heatmap in processing large amounts of data. Twenty-seven volunteers were imaged using ultrasound at three different neck levels on right and left sides and various anatomical parameters were measured. Demographic information was also collected and included in the data processing. The Pearson coefficient was derived from each possible relationship between the measured parameters and was plotted in a correlation heatmap. Strong correlations were observed between the body mass index and the depth of the IJV and common carotid artery (CCA), the relative depth of the IJV to the CCA. No significant correlations were found in the dimensions of both vessels. Anatomical variations were more common than anticipated and should be taken into account when performing central line catheterization in order to minimize post-procedure complications.
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Affiliation(s)
- Anna Iankovitch
- St. George's University School of Medicine, St. George's University, Grenada, West Indies
| | - Johanna Shapiro Ledley
- St. George's University School of Medicine, St. George's University, Grenada, West Indies
| | - Tarek Almabrouk
- Department of Anatomy, St. George's University School of Medicine, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Nahidh Al-Jaberi
- Department of Anatomy, St. George's University School of Medicine, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - James Coey
- St. George's University School of Medicine, St. George's University, Grenada, West Indies.,Department of Anatomy, St. George's University School of Medicine, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
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GÜRSOY D, AKÇAM Tİ, TEKNECİ AK, ÇAKAN A. Santral venöz kateterin neden olduğu venöz tromboz zemininde gelişen şilotoraks olgusu. EGE TIP DERGISI 2022. [DOI: 10.19161/etd.1208976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Venöz tromboz (VT) santral venöz kateterizasyon (SVK) sonucu ortaya çıkabilmektedir. VT duktus torasikus’un drene olduğu angulus venosus’a uzanıp lenfatik akımı engellediğinde şilotoraks gelişebilmektedir. Uzun süreli SVK’ya bağlı VT sonucu şilotoraks ortaya çıkan ve yaşamını yitiren 76 yaşındaki bir olgu sunularak; hem VT’nin şilotoraks nedeni olabileceği hem de SVK’lı olguların tromboz gelişimi açısından düzenli kontrollerinin yapılması gerektiği vurgulanmak istenmiştir.
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Affiliation(s)
- Dilara GÜRSOY
- Ege Üniversitesi Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, İzmir, Türkiye
| | - Tevfik İlker AKÇAM
- Ege Üniversitesi Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, İzmir, Türkiye
| | | | - Alpaslan ÇAKAN
- Ege Üniversitesi Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, İzmir, Türkiye
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Cherara L, Sculli GL, Paull DE, Mazzia L, Neily J, Mills PD. Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem. J Patient Saf 2021; 17:e911-e917. [PMID: 29443720 DOI: 10.1097/pts.0000000000000475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aims of this study were to investigate the demographics, causes, and contributing factors of retained guidewires (GWs) and to make specific recommendations for their prevention. METHODS The Veterans Administration patient safety reporting system database for 2000-2016 was queried for cases of retained GWs (RGWs). Data extracted for each case included procedure location, provider experience, insertion site, urgency, time to discovery, root causes, and corrective actions taken. RESULTS There were 101 evaluable cases of RGWs. Resident trainee (36%), critical care unit (38%), femoral vein (44%), and nonemergent placement (79%) were the conditions most frequently associated with a RGW. While discovery occurred almost immediately (30%) or in next 24 hours (31%), there were instances of RGWs found months (2%) or years (3%) later. Common root causes included inexperience (46%), lack of standardization (35%), distractions (25%), and lack of a checklist (23%). CONCLUSIONS The results demonstrate the result of human factors-based errors such as posttask completion errors. We recommend human factor-based interventions such as checklists and devices employing forcing functions that do not allow clinicians to complete the insertion process without first removing the GW.
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Affiliation(s)
| | - Gary L Sculli
- From the Veterans Health Administration National Center for Patient Safety, Ann Arbor
| | | | - Lisa Mazzia
- From the Veterans Health Administration National Center for Patient Safety, Ann Arbor
| | - Julia Neily
- From the Veterans Health Administration National Center for Patient Safety, Ann Arbor
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Jo S, Kang HM, Kim SK, Lee JW, Chung NG, Cho B, Jeong DC, Park YJ. Source Identification of Klebsiella pneumoniae Causing Six Episodes of Recurrent Sepsis in an Adolescent That Underwent Hematopoietic Stem Cell Transplantation. Pathogens 2021; 10:pathogens10091123. [PMID: 34578155 PMCID: PMC8468436 DOI: 10.3390/pathogens10091123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/23/2021] [Accepted: 09/01/2021] [Indexed: 11/20/2022] Open
Abstract
Septicemia or bacteremia is one of the leading causes of death worldwide. Long-term tunneled central venous catheters (CVCs) are usually placed in children undergoing chemotherapy or hematopoietic stem cell transplantation (HSCT) for underlying hemato–oncologic malignancies. However, catheter-related complications have been reported frequently, and there is high morbidity and mortality related to catheter-line-associated bloodstream infections (CLABSIs). We report a rare case of six episodes of recurrent K. pneumoniae sepsis within a 6-month period in a 12-year-old male adolescent that underwent HSCT for acute lymphoblastic leukemia, despite treatment with susceptible antibiotics. The patient received extensive diagnostic evaluations to find the hidden source; however, failure to discover the primary source led to multiple recurrences. Through enterobacterial repetitive intergenic consensus (ERIC)-PCR, we were able to identify the relationship between the six episodes and recognize the source of bacteremia.
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Affiliation(s)
- Suejung Jo
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.J.); (S.K.K.); (J.W.L.); (N.-G.C.); (B.C.); (D.C.J.)
| | - Hyun Mi Kang
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.J.); (S.K.K.); (J.W.L.); (N.-G.C.); (B.C.); (D.C.J.)
- Correspondence: ; Tel.: +82-2-2258-6273; Fax: +82-2-537-4544
| | - Seong Koo Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.J.); (S.K.K.); (J.W.L.); (N.-G.C.); (B.C.); (D.C.J.)
| | - Jae Wook Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.J.); (S.K.K.); (J.W.L.); (N.-G.C.); (B.C.); (D.C.J.)
| | - Nack-Gyun Chung
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.J.); (S.K.K.); (J.W.L.); (N.-G.C.); (B.C.); (D.C.J.)
| | - Bin Cho
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.J.); (S.K.K.); (J.W.L.); (N.-G.C.); (B.C.); (D.C.J.)
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.J.); (S.K.K.); (J.W.L.); (N.-G.C.); (B.C.); (D.C.J.)
| | - Yeon-Joon Park
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
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Inadvertent subclavian artery catheter insertion. J Vasc Surg 2021; 73:309-310. [PMID: 33349384 DOI: 10.1016/j.jvs.2020.04.514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/22/2020] [Indexed: 11/22/2022]
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9
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Sasson M, Montorfano L, Bordes SJ, Sarmiento Cobos M, Grove M. Subclavian Artery Injury Following Central Venous Catheter Placement. Cureus 2021; 13:e14287. [PMID: 33968501 PMCID: PMC8096622 DOI: 10.7759/cureus.14287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2021] [Indexed: 01/23/2023] Open
Abstract
Mechanical complications following central venous catheterization are not uncommon. We discuss a case of iatrogenic intra-arterial central venous catheter placement requiring neck exploration in a 93-year-old woman. The catheter was inadvertently passed through the jugular vein and into the right subclavian artery by a junior surgical resident. Adequate technique and supervision, ultrasound guidance, and immediate diagnostic workup in the event of suspected arterial injury are factors necessary for physicians to minimize complications and provide safe medical treatment.
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Affiliation(s)
- Morris Sasson
- Vascular Surgery, Cleveland Clinic Florida, Weston, USA
| | | | - Stephen J Bordes
- Surgical Anatomy, Tulane University School of Medicine, New Orleans, USA
| | | | - Mark Grove
- Vascular Surgery, Cleveland Clinic Florida, Weston, USA
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10
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Schulz J, Scholler A, Frank P, Scheinichen D, Flentje M, Eismann H, Palmaers T. [Complications and success rates of subclavian vein catheterization depending on experience]. Anaesthesist 2020; 70:291-297. [PMID: 33231715 PMCID: PMC8026418 DOI: 10.1007/s00101-020-00888-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 10/18/2020] [Accepted: 10/27/2020] [Indexed: 10/31/2022]
Abstract
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.
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Affiliation(s)
- Johannes Schulz
- Klinik für Anästhesiologie und Intensivmedizin (OE8050), Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Axel Scholler
- Anästhesiologische Klinik, Universitätsklinikum Erlangen, Maximiliansplatz 1, 91054, Erlangen, Deutschland
| | - Paul Frank
- Klinik für Anästhesiologie und Intensivmedizin (OE8050), Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Dirk Scheinichen
- Klinik für Anästhesiologie und Intensivmedizin (OE8050), Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Markus Flentje
- Klinik für Anästhesiologie und Intensivmedizin (OE8050), Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Hendrik Eismann
- Klinik für Anästhesiologie und Intensivmedizin (OE8050), Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Thomas Palmaers
- Klinik für Anästhesiologie und Intensivmedizin (OE8050), Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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11
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Palmaers T, Frank P, Eismann H, Sieg L, Leffler A, Schmitt H, Scholler A. [Catheterization of the subclavian vein and the risk of pneumothorax : Mechanical ventilation increases the risk of pneumothorax during infraclavicular landmark-guided subclavian vein puncture: a prospective randomized study]. Anaesthesist 2020; 68:309-316. [PMID: 30899972 DOI: 10.1007/s00101-019-0579-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Infraclavicular subclavian vein (SCV) catheterization is a standard procedure in anesthesia and intensive care. There is a lack of evidence on how mechanical ventilation during venipuncture of the SCV influences pneumothorax rates. OBJECTIVE Primary hypothesis: non-inferiority of continuing vs. discontinuing mechanical ventilation during infraclavicular puncture of the SCV with respect to the pneumothorax rate. MATERIAL AND METHODS This prospective, randomized and single-blinded study was approved by the local ethics committee. A total of 1021 eligible patients who underwent cranial neurosurgery in 2 different university hospitals were assessed between August 2014 and October 2017. Patients were randomly assigned to two groups directly before induction of anesthesia. Intervention groups for venipuncture of the SCV were mechanical ventilation: tidal volume 7 ml/kg ideal body weight, positive end expiratory pressure (PEEP) ideal body weight/10, n = 535, or apnea: manual/spontaneous, APL valve 0 mbar, n = 486. Patients and the physicians who assessed pneumothorax rates were blinded to the intervention group. Venipuncture was carried out by both inexperienced and experienced physicians. RESULTS The pneumothorax rate was significantly higher in the mechanical ventilation group (2.2% vs. 0.4%; p = 0.012) with an odds ratio (OR) of 5.63 (95% confidence interval, CI: 1.17-27.2; p = 0.031). A lower body mass index (BMI) was associated with a higher pneumothorax rate, OR 0.89 (95% CI: 0.70-0.96; p = 0.013). CONCLUSION In this study landmark-guided infraclavicular SCV catheterization was associated with a significantly higher rate of pneumothorax when venipuncture was performed during mechanical ventilation and not in apnea. If a short phase of apnea is justifiable in the patient, mechanical ventilation should be discontinued during the venipuncture procedure.
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Affiliation(s)
- T Palmaers
- Klinik für Anästhesiologie und Intensivmedizin (OE8050), Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - P Frank
- Klinik für Anästhesiologie und Intensivmedizin (OE8050), Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - H Eismann
- Klinik für Anästhesiologie und Intensivmedizin (OE8050), Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - L Sieg
- Klinik für Anästhesiologie und Intensivmedizin (OE8050), Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - A Leffler
- Klinik für Anästhesiologie und Intensivmedizin (OE8050), Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - H Schmitt
- Anästhesiologische Klinik, Universitätsklinikum Erlangen, Maximiliansplatz 1, 91054, Erlangen, Deutschland
| | - A Scholler
- Anästhesiologische Klinik, Universitätsklinikum Erlangen, Maximiliansplatz 1, 91054, Erlangen, Deutschland
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Ostroff MD, Pittiruti M. Alternative exit sites for central venous access: Back tunneling to the scapular region and distal tunneling to the patellar region. J Vasc Access 2020; 22:992-996. [PMID: 32644003 DOI: 10.1177/1129729820940178] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Uncooperative elderly patients with cognitive disorder are often confused and/or agitated. Risk of involuntary venous access device dislodgment is high in these patients. This is equally likely with peripherally inserted central catheters and centrally inserted central catheters but less common with femorally inserted central catheters. Solutions to this problem include strict continuous patient observation, using sutures or subcutaneous anchored securement, wrapping the arm to “hide” the line, or using soft mittens to occupy the hands. However, some patients are able to disrupt the dressing, dislodge the catheter, and often pull the catheter out completely. In some cases, the patient may also overcome the resistance offered by the stitches or by the subcutaneous anchored securement device. In a recent paper on the impact of subcutaneously anchored securement in preventing dislodgment, the only demonstrated failures occurred in non-compliant elderly patients. Creation of an alternative exit site is an emerging trend in patients with cognitive impairment at high risk for catheter dislodgement. Subcutaneous tunneling from traditional insertion sites such as the jugular, axillary, or femoral veins allows placement of the exit site in a region inaccessible to the patient. The following two case reports demonstrate the technique for tunneling a femorally inserted central catheter downward to the patellar region and for tunneling a centrally inserted central catheter to the scapular region. Internal review board approval was not deemed necessary as subcutaneous tunneling is not a new technique. In our experience, such maneuvers can be successfully performed at the bedside.
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13
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Raina R, Mittal A, Sethi SK, Chakraborty R. Challenges of Vascular Access in the Pediatric Population. Adv Chronic Kidney Dis 2020; 27:268-275. [PMID: 32891312 DOI: 10.1053/j.ackd.2020.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/18/2020] [Accepted: 02/20/2020] [Indexed: 11/11/2022]
Abstract
The incidence and prevalence of renal replacement therapy has continued to increase in the pediatric population. Recent data have shown that hemodialysis was the most frequently used dialysis modality, especially in pediatric ESRD patients (age 0-21 years). A well-functioning vascular access is required for effective hemodialysis and choosing the best vascular access option for pediatric patients can be difficult. Pediatric vascular options include arteriovenous fistula, arteriovenous graft, and central venous catheters (CVCs). There is a national initiative for fistula first-catheter last approach; however, CVCs have been reported as the most conventionally utilized vascular access option in pediatric patients. The use of CVCs should be minimized or avoided as they are associated with high risk of infections, thrombosis, and other complications. Thus, it is important for practitioners to plan appropriately in advance, practice good clinical judgment, and assure that the best vascular access is placed according to the patient's needs. Therefore, this article reviews the different types of pediatric vascular access and the associated benefits and potential complications of each.
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14
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Stowell JR, Rigdon D, Colglazier R, Filler L, Orosco D, Connell M, Akhter M, Mitchell C. Risk of contrast extravasation with vascular access in computed tomography. Emerg Radiol 2020; 27:253-258. [PMID: 31919617 DOI: 10.1007/s10140-020-01752-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/03/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Diagnostic computed tomography (CT) imaging, utilizing intravenous (IV) contrast administration, has become increasingly common. Potential IV contrast-associated complications include local skin and soft tissue reactions due to extravasation. The goal of this study is to describe the risk of contrast extravasation based on IV catheter anatomic location in patients receiving contrast-enhanced CT imaging. METHODS The study was conducted as a retrospective cohort study of patients receiving contrast-enhanced CT imaging performed over a 26-month period at a single institution. The rate of contrast extravasation was calculated by IV catheter vessel anatomic location and compared by relative risk (RR) and absolute risk reduction (ARR). RESULTS Of 17,767 contrast administrations for CT imaging studies performed, 14,558 met study inclusion criteria. Forty-nine (0.34%) extravasation events were identified. Forty-one (0.28%, 95% CI 0.21-0.39%) extravasation events were observed in 14,275 peripheral IV catheters placed in a non-upper arm location. Eight (2.8%, 95% CI 1.3-5.3%) extravasation events were observed in 283 IV catheters placed, most commonly with point-of-care ultrasound (POCUS) guidance, in upper arm vessels (RR 10.1, 95% CI 4.69-21.8). Non-upper arm located IV catheters were associated with an ARR of 2.54% (95% CI 0.61-4.47%) when compared to upper arm catheters. CONCLUSIONS IV catheter placement in upper arm vessels is associated with a relatively minimal increase in extravasation risk when compared to catheters placed in a non-upper arm location. In patients without alternative available peripheral vascular access, POCUS-guided upper arm IV cannulation may be an appropriate approach.
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Affiliation(s)
- Jeffrey R Stowell
- Department of Emergency Medicine, Maricopa Integrated Health System, 2601 E Roosevelt St, Phoenix, AZ, 85008, USA.
- Department of Emergency Medicine, University of Arizona College of Medicine- Phoenix, 475 N 5th St, Phoenix, AZ, 85004, USA.
- Department of Emergency Medicine, Creighton University School of Medicine, 7500 Mercy Rd, Omaha, NE, 68124, USA.
| | - Daniel Rigdon
- Department of Emergency Medicine, Maricopa Integrated Health System, 2601 E Roosevelt St, Phoenix, AZ, 85008, USA
| | - Roy Colglazier
- Department of Radiology, Maricopa Integrated Health System, 2601 E Roosevelt St, Phoenix, AZ, 85008, USA
| | - Levi Filler
- Department of Emergency Medicine, Maricopa Integrated Health System, 2601 E Roosevelt St, Phoenix, AZ, 85008, USA
| | - Daniel Orosco
- Department of Emergency Medicine, Maricopa Integrated Health System, 2601 E Roosevelt St, Phoenix, AZ, 85008, USA
| | - Mary Connell
- Department of Radiology, Maricopa Integrated Health System, 2601 E Roosevelt St, Phoenix, AZ, 85008, USA
| | - Murtaza Akhter
- Department of Emergency Medicine, Maricopa Integrated Health System, 2601 E Roosevelt St, Phoenix, AZ, 85008, USA
- Department of Emergency Medicine, University of Arizona College of Medicine- Phoenix, 475 N 5th St, Phoenix, AZ, 85004, USA
- Department of Emergency Medicine, Creighton University School of Medicine, 7500 Mercy Rd, Omaha, NE, 68124, USA
| | - Carl Mitchell
- Department of Emergency Medicine, Maricopa Integrated Health System, 2601 E Roosevelt St, Phoenix, AZ, 85008, USA
- Department of Emergency Medicine, University of Arizona College of Medicine- Phoenix, 475 N 5th St, Phoenix, AZ, 85004, USA
- Department of Emergency Medicine, Creighton University School of Medicine, 7500 Mercy Rd, Omaha, NE, 68124, USA
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15
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Riley LE, Ataya A. Clinical approach and review of causes of a chylothorax. Respir Med 2019; 157:7-13. [PMID: 31454675 DOI: 10.1016/j.rmed.2019.08.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 08/12/2019] [Accepted: 08/20/2019] [Indexed: 12/16/2022]
Abstract
A chylothorax, also known as chylous pleural effusion, is an uncommon cause of pleural effusion with a wide differential diagnosis characterized by the accumulation of bacteriostatic chyle in the pleural space. The pleural fluid will have either or both triglycerides >110 mg/dL and the presence of chylomicrons. It may be encountered following a surgical intervention, usually in the chest, or underlying disease process. Management of a chylothorax requires a multidisciplinary approach employing medical therapy and possibly surgical intervention for post-operative patients and patients who have failed medical therapy. In this review, we aim to discuss the anatomy, fluid characteristics, etiology, and approach to the diagnosis of a chylothorax.
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Affiliation(s)
- Leonard E Riley
- University of Florida College of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Gainesville, FL, USA
| | - Ali Ataya
- University of Florida College of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Gainesville, FL, USA.
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Maitra S, Bhattacharjee S, Baidya DK. Comparison of long-, short-, and oblique-axis approaches for ultrasound-guided internal jugular vein cannulation: A network meta-analysis. J Vasc Access 2019; 21:204-209. [PMID: 31423893 DOI: 10.1177/1129729819868927] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Comparison between various approaches of ultrasound (USG)-guided internal jugular vein cannulation, that is, short-axis out-of-plane approach, long-axis in-plane approach, and oblique-axis approach, is sparse. In this network meta-analysis of randomized controlled trials, all three approaches were evaluated to identify the best technique for USG-guided internal jugular vein cannulation. METHODS Randomized controlled trials comparing short-axis out-of-plane approach, long-axis in-plane approach, and oblique-axis approach in any combination (i.e. comparison of any two or all three) for USG-guided internal jugular vein cannulation were included in this meta-analysis. Bayesian network meta-analysis was conducted with a non-informative prior effect size and heterogeneity, and all results were reported as posterior median odds ratio with 95% credible interval. RESULTS Data of 658 patients from five randomized controlled trials were included in this meta-analysis. No difference was obtained in first attempt success rate of cannulation in three approaches (posterior median odds ratio between long-axis and short-axis view, oblique-axis and short-axis view, and long-axis and oblique-axis view were 0.67 (0.20, 2.08), 0.92 (0.09, 4.790), and 1.3420 (0.1680, 6.7820), respectively). No difference was seen in the incidence of carotid artery puncture and overall success rate of cannulation. CONCLUSION All three commonly used approaches for USG-guided internal jugular vein cannulation, that is, short axis, long axis, and oblique axis, are comparable in terms of clinical utility and safety. There is insufficient evidence to recommend one approach over another for this purpose.
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Affiliation(s)
- Souvik Maitra
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, New Delhi, India
| | - Sulagna Bhattacharjee
- Department of Anaesthesia & Critical Care, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Dalim K Baidya
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, New Delhi, India
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Sugak AB, Shchukin VV, Konstantinova AN, Feoktistova EV. Complications of central venous catheters insertion and exploitation. ACTA ACUST UNITED AC 2019. [DOI: 10.24287/1726-1708-2019-18-1-127-139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- A. B. Sugak
- Dmitriy Rogachev National Medical Research Center of Pediatric Hematology, Oncology, Immunology Ministry of Healthcare of Russian Federation
| | - V. V. Shchukin
- Dmitriy Rogachev National Medical Research Center of Pediatric Hematology, Oncology, Immunology Ministry of Healthcare of Russian Federation; Russian National Research Medical University named after N.I. Pirogov
| | - A. N. Konstantinova
- Dmitriy Rogachev National Medical Research Center of Pediatric Hematology, Oncology, Immunology Ministry of Healthcare of Russian Federation
| | - E. V. Feoktistova
- Dmitriy Rogachev National Medical Research Center of Pediatric Hematology, Oncology, Immunology Ministry of Healthcare of Russian Federation
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Abstract
Objectives: To present an unusual major mechanical complication of central venous catheterization (CVC). Methods: Between January 2016 and January 2017, data of the patients who underwent CVC in Cumhuriyet University in Sivas, Turkey, were retrospectively reviewed. The patients who experienced an unusual mechanical catheter-related complication are included in this study. Other complications of central venous catheter placement, except mechanical catheter complications such as infection or thrombosis, were excluded from the study. Results: A total of 236 consecutive patients who had undergone CVC were found. Nine patients (3.8%) were found to have unusual major mechanical catheter complications. Most noteworthy complications occurred when the catheter was placed in the arcus aorta, ductus thoracicus, pleural cavity, and abdominal cavity. The most common observation in patients with major complications was that CVC had been carried out in the absence of ultrasonic or fluoroscopic guidance owing to emergency situations. Conclusion: The use of CVC is associated with potential major complications occurring particularly during emergency situations. We believe that the use of radiological guidance during CVC could reduce unusual major mechanical complication rates even during an emergency situation.
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Affiliation(s)
- Nurkay Katrancioglu
- Department of Cardiovascular Surgery, Cumhuriyet University, School of Medicine, Sivas, Turkey. E-mail.
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Bonatti HJ. Accidental placement of an infusaport into the pulmonary artery: Case report and review of the literature. Respir Med Case Rep 2018; 26:78-81. [PMID: 30555781 PMCID: PMC6279962 DOI: 10.1016/j.rmcr.2018.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/01/2018] [Indexed: 12/20/2022] Open
Abstract
Background Misplacement of central venous catheters (CVC) may have devastating consequences. Patients and methods Placement of a CVC into the pulmonary artery (PA) and management of the complication is described. Literature search for accidental direct placement of CVCs into the PA was performed. Results A 46 year old morbidly obese female required an infusaport for chemotherapy. She was anaesthetized and placed in Trendelenburg. Three attempts to access the left subclavian vein (LSCV) using landmarks failed. In steeper Trendelenburg, a blood vessels was accessed. Non pulsatile dark blood was aspirated, a guidewire was easily advanced. Fluoroscopy projected the guidewire tip over the right atrium; infusaport placement was without difficulties. Postoperative chest x-ray showed the tube initially pointing caudally, then traversing the midline with the tip projecting over the right atrium. Emergent angiogram showed placement of the tube into the mainstem of the PA. The tube was removed; CT-angiogram showed no extravasation but a 3cm left mediastinal hematoma. Transfer to an ICU in a facility offering emergent cardiothoracic surgery was done. She remained stable, repeat CT-scan showed decreased hematoma size and she was retransferred. The infusaport was placed under ultrasound guidance into the left jugular vein. Six additional cases of direct puncture of the PA were reported; in all except one the LSCV had been targeted. No patient died directly from the complication, all catheters were removed, four patients required surgery or interventional procedures. Conclusions Accidental placement of CVC s into the PA is a rare complication. The catheter should be removed. Patients should be urgently transferred to a center with access to interventional radiology and cardiothoracic surgery.
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Affiliation(s)
- Hugo J.R. Bonatti
- University of Maryland Community Medical Group, Easton, MD, USA
- Meritus Surgical Specialists, Hagerstown, MD, USA
- Meritus Surgical Specialists, 11110 Medical Campus Road, Suite 147, Hagerstown, MD 21742, USA.
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Molina-Mazón CS, Martín-Cerezo X, Domene-Nieves de la Vega G, Asensio-Flores S, Adamuz-Tomás J. Comparative study on fixation of central venous catheter by suture versus adhesive device. ENFERMERIA INTENSIVA 2018; 29:103-112. [PMID: 29602709 DOI: 10.1016/j.enfi.2017.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/19/2017] [Accepted: 10/23/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To assess the efficacy of a central venous catheter adhesive fixation device (CVC) to prevent associated complications. To establish the need for dressing changes, number of days' catheterization and reasons for catheter removal in both study groups. To assess the degree of satisfaction of personnel with the adhesive system. METHOD A, randomized, prospective and open pilot study, of parallel groups, with comparative evaluation between CVC fixation with suture and with an adhesive safety system. The study was performed in the Coronary Unit of the Universitari de Bellvitge Hospital, between April and November 2016. The population studied were patients with a CVC. The results were analyzed using SPSS Statistics software. The study was approved by the Clinical Research Ethics Committee. RESULTS 100 patients (47 adhesive system and 53 suture) were analyzed. Both groups were homogeneous in terms of demographic variables, anticoagulation and days of catheterization. The frequency of complications in the adhesive system group was 21.3%, while in the suture group it was 47.2% (P=.01). The suture group had a higher frequency of local signs of infection (p=.006), catheter displacement (p=.005), and catheter-associated bacteraemia (P=.05). The use of adhesive fixation was associated with a lower requirement for dressing changes due to bleeding (P=.006). Ninety-six point seven percent of the staff recommended using the adhesive safety system. CONCLUSIONS The catheters fixed with adhesive systems had fewer infectious complications and less displacement.
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Affiliation(s)
- C S Molina-Mazón
- Unidad de Cuidados Intensivos Cardiológicos y Unidad de Electrofisiología y Arritmias, Hospital Universitari de Bellvitge. GRIN, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, España; Sistema de Emergencias Médicas de Cataluña, España.
| | - X Martín-Cerezo
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - G Domene-Nieves de la Vega
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - S Asensio-Flores
- Área de Enfermedades del Corazón, Hospital Universitari de Bellvitge. GRIN, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, España
| | - J Adamuz-Tomás
- Unidad de Soporte Enfermero a los Sistemas de Información y Soporte a la Investigación, Hospital Universitario de Bellvitge. GRIN, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, España; Facultad de Medicina y Ciencias de la Salud, Departamento de Enfermería, Universidad de Barcelona, L'Hospitalet de Llobregat, Barcelona, España
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Struck MF, Ewens S, Schummer W, Busch T, Bernhard M, Fakler JKM, Stumpp P, Stehr SN, Josten C, Wrigge H. Central venous catheterization for acute trauma resuscitation: Tip position analysis using routine emergency computed tomography. J Vasc Access 2018. [PMID: 29529967 DOI: 10.1177/1129729818758998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Central venous catheter insertion for acute trauma resuscitation may be associated with mechanical complications, but studies on the exact central venous catheter tip positions are not available. The goal of the study was to analyze central venous catheter tip positions using routine emergency computed tomography. METHODS Consecutive acute multiple trauma patients requiring large-bore thoracocervical central venous catheters in the resuscitation room of a university hospital were enrolled retrospectively from 2010 to 2015. Patients who received a routine emergency chest computed tomography were analyzed regarding central venous catheter tip position. The central venous catheter tip position was defined as correct if the catheter tip was placed less than 1 cm inside the right atrium relative to the cavoatrial junction, and the simultaneous angle of the central venous catheter tip compared with the lateral border of the superior vena cava was below 40°. RESULTS During the 6-year study period, 97 patients were analyzed for the central venous catheter tip position in computed tomography. Malpositions were observed in 29 patients (29.9%). Patients with malpositioned central venous catheters presented with a higher rate of shock (systolic blood pressure <90 mmHg) at admission (58.6% vs 33.8%, p = 0.023) and a higher mean injury severity score (38.5 ± 15.7 vs 31.6 ± 11.8, p = 0.041) compared with patients with correctly positioned central venous catheter tips. Logistic regression revealed injury severity score as a significant predictor for central venous catheter malposition (odds ratio = 1.039, 95% confidence interval = 1.005-1.074, p = 0.024). CONCLUSION Multiple trauma patients who underwent emergency central venous catheter placement by experienced anesthetists presented with considerable tip malposition in computed tomography, which was significantly associated with a higher injury severity.
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Affiliation(s)
- Manuel F Struck
- 1 Department of Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Sebastian Ewens
- 2 Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Wolfram Schummer
- 3 Department of Anaesthesiology and Intensive Care Medicine, University Hospital Jena, Jena, Germany.,4 Department of Anaesthesia and Pain Therapy, Helios Spital Überlingen, Überlingen, Germany
| | - Thilo Busch
- 1 Department of Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Michael Bernhard
- 5 Emergency Department, University Hospital Leipzig, Leipzig, Germany
| | - Johannes K M Fakler
- 6 Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Patrick Stumpp
- 2 Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Sebastian N Stehr
- 1 Department of Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Christoph Josten
- 6 Department of Orthopedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Hermann Wrigge
- 1 Department of Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
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22
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Struck MF, Fakler JKM, Bernhard M, Busch T, Stumpp P, Hempel G, Beilicke A, Stehr SN, Josten C, Wrigge H. Mechanical complications and outcomes following invasive emergency procedures in severely injured trauma patients. Sci Rep 2018; 8:3976. [PMID: 29507415 PMCID: PMC5838247 DOI: 10.1038/s41598-018-22457-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 02/23/2018] [Indexed: 11/16/2022] Open
Abstract
This study aimes to determine the complication rates, possible risk factors and outcomes of emergency procedures performed during resuscitation of severely injured patients. The medical records of patients with an injury severity score (ISS) >15 admitted to the University Hospital Leipzig from 2010 to 2015 were reviewed. Within the first 24 hours of treatment, 526 patients had an overall mechanical complication rate of 26.2%. Multivariate analysis revealed out-of-hospital airway management (OR 3.140; 95% CI 1.963–5.023; p < 0.001) and ISS (per ISS point: OR 1.024; 95% CI 1.003–1.045; p = 0.027) as independent predictors of any mechanical complications. Airway management complications (13.2%) and central venous catheter complications (11.4%) were associated with ISS >32.5 (p < 0.001) and ISS >33.5 (p = 0.005), respectively. Chest tube complications (15.8%) were associated with out-of-hospital insertion (p = 0.002) and out-of-hospital tracheal intubation (p = 0.033). Arterial line complications (9.4%) were associated with admission serum lactate >4.95 mmol/L (p = 0.001) and base excess <−4.05 mmol/L (p = 0.008). In multivariate analysis, complications were associated with an increased length of stay in the intensive care unit (p = 0.019) but not with 24 hour mortality (p = 0.930). Increasing injury severity may contribute to higher complexity of the individual emergency treatment and is thus associated with higher mechanical complication rates providing potential for further harm.
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Affiliation(s)
- Manuel F Struck
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| | - Johannes K M Fakler
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Thilo Busch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Patrick Stumpp
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Gunther Hempel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - André Beilicke
- Emergency Department, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Sebastian N Stehr
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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