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Direct puncture of a thrombosed lower extremity bypass graft may be the only angiographic access to the graft when it cannot be opacified or cannulated by conventional angiographic techniques. In 1 patient, fibrinolytic therapy was performed from this approach using the "crossed two catheter" technique previously described for thrombosed dialysis grafts.
STUDY OBJECTIVE: The optimal out-of-hospital treatment for trauma patients remains a subject of national debate. Researchers designing future studies to address these issues must understand the variability in treatment that exists across the United States. We define the variability in the out-of-hospital treatment provided to trauma patients in the United States. METHODS: This was a retrospective analysis of prospectively collected data for a cohort study of trauma outcomes. The study was conducted at 15 urban or suburban regions across the United States, 18 Level I trauma centers and 51 nontrauma centers. We used a weighted population sample based on data from all hospital trauma deaths and a sample of patients discharged between January 2001 and December 2002. Entry criteria included at least 1 body region with an Abbreviated Injury Score greater than 3 and age between 18 and 84 years. Exclusion criteria were patient age greater than 65 years and isolated hip fractures and patients with burns. RESULTS: Complete out-of-hospital data were available for 3,357 patients, representing a weighted population sample of 9,929 patients. Out-of-hospital treatment varied substantially among the regions, including out-of-hospital intubation (5% to 48%), use of neuromuscular blocking agents or sedatives to facilitate intubation (0% to 100%), surgical airway access (0.1% to 3.5%), peripheral and central intravenous access (22% to 95%), and needle thoracentesis (0% to 5%). CONCLUSION: There is considerable national variability in out-of-hospital procedures performed for trauma patients.
Prior intravenous cannulation (IVC) injectable preanesthetic research has focused primarily on the presurgical population. This focus may diminish the applicability of these findings to the rest of the adult inpatient population. To gain a full perspective of the IVC experience, it is important to use samples that are representative of the entire population that health care providers see in practice. This study is the first to examine the adult medical inpatient pain response associated with peripheral IVC for patients receiving subcutaneous buffered lidocaine 1%, subcutaneous normal saline 0.9% with the preservative benzyl alcohol, or no treatment. Further investigation is needed to build on the previous and current research to enhance a clinicians ability to provide individualized IVC preanesthetic treatment options.
We describe a delayed case of Horner's syndrome after the use of a peripherally inserted central line. Central vein thrombosis, a well-recognized complication of central venous access, led to temporary injury to the sympathetic tract in the neck. Presentation of Horner's syndrome with central venous access in place should be further investigated to rule out central vein thrombosis.
Peripherally inserted central catheters (PICCs) can meet the needs of patients requiring short- to intermediate-term intravenous therapy in a variety of settings. PICCs minimise insertion and catheter-related complications when compared to other central venous access devices (CVADs). PICCs have been introduced in the UK mainly through innovative advanced nursing practice.
Pleural effusion secondary to vascular perforation and leakage of total parenteral nutrition (TPN) is a rare complication of central lines. We report such a case and urge physicians to familiarize with recognition and management of this rare complication as both TPN and central catheter lines are widely used techniques.
We report on our experience in the use of a new system of a totally implantable device for repeated vascular access in children, developed in 1989 by Pharmacia and named P.A.S. Port (Peripheral Access System Port). The P.A.S. Port is far smaller than other systems and has been designed for peripheral location in the arm. This avoids unsightly pectoral scars particularly in girls and allows insertion under local anesthesia. It is an interesting alternative to the Port-a-Cath for children older than 5 years of age. It is easily accepted by the patient as well as by the caring team.
UNLABELLED: This study aimed at constructing learning curves for basic procedural skills in anesthesiology using the cumulative sum method. We recorded 1234 peripheral venous cannulations, 895 orotracheal intubations, 688 spinals, and 344 epidurals performed by residents during the first 10 mo of training. Learning curves for each procedure were constructed by using the cusum method. The number of procedures performed until attainment of acceptable failure rates was calculated. All residents mastered peripheral venous cannulation after 79 +/- 47 procedures. Four of 7 residents attained acceptable failure rates at orotracheal intubation after 43 +/- 33 proce- dures. Seven of 11 residents attained acceptable failure rates at spinal anesthesia after 36 +/- 20 procedures. At epidural anesthesia, 5 of 11 residents attained acceptable failure rates after 21 +/- 11 procedures. The cusum method is a useful tool for objectively measuring performance during the learning phase of basic procedures. The wide interindividual variability in the number of procedures required to be performed before attaining acceptable failure rates suggests that performance should be followed on an individual basis. IMPLICATIONS: Learning curves for peripheral venous cannulation, tracheal intubation, and spinal and epidural anesthesia were constructed using the cumulative sum (cusum) method. There was a wide variability in the number of procedures performed until attainment of acceptable failure rates. The cusum method may improve our means of evaluating residents' technical skills.
AIMS/BACKGROUND: This study was undertaken in order to characterize the liver injury induced by transcatheter arterial chemoembolization therapy (TACE) for hepatocellular carcinoma (HCC) and to elucidate-mechanisms involved in the growth of mononuclear phagocytes in injured human liver in vivo. PATIENTS AND METHODS: The serum levels of macrophage-colony stimulating factor (M-CSF) along with clinical parameters were examined in 43 patients with HCC who underwent TACE. Ten patients who underwent angiography alone served as controls. RESULTS: Serum M-CSF increased and peaked on the third day after TACE showing significant correlations (p < 0.001, respectively) with the increases in serum alanine aminotransferase (ALT) and type IV collagen-7S (IVcol-7S). The lipopolysaccharide-stimulated production of interleukin (IL)-1 beta, IL-6, and tumor necrosis factor (TNF)-alpha in peripheral whole blood increased and peaked on the first or on the third day after TACE. In effective cases of TACE, significantly (p < 0.05) greater increases in serum M-CSF were noted as compared with those in ineffective cases. DISCUSSION: The serum levels of M-CSF increased after TACE in correlation with hepatic inflammation and necrosis and increased production of IL-1 beta, TNF-alpha and IL-6 in peripheral whole blood. These results suggest a mechanism by which hepatic injury enhances the production of M-CSF via a cytokine cascade, which results in the proliferation of liver macrophages in vivo.
Application of the topical anesthetic cream to the antecubital fossa 60 minutes before insertion of the peripherally inserted central catheters resulted in significant vasoconstriction and/or vasospasm in 24 patients. Catheter insertion was difficult in all 24 patients. Advancement of the peripherally inserted central catheter was impossible in six patients. Of the 51 patients that did not have the topical anesthetic pre-catheter insertion, there were no difficulties in placing the lines, nor were there any vasoconstriction and/or vasospasm. This group included 66 adults and 9 children.
Transmission of infection in the hospital has been identified as a patient safety problem adversely affecting patients, visitors, and health care workers. Prevention of infection should not be limited to the hospital epidemiology staff but also must involve the entire multidisciplinary team, including nurses. This chapter reviews the literature related to patient safety of nursing-authored studies of infection control in the hospital. The review indicated that there were key areas of research interest including drug resistance; hand hygiene products, procedures, and surveillance; preoperative skin preparations; health care worker transmission of infection; common procedures associated with an increased risk of transmission; and organizational issues.
A prospective study was performed to assess the value of differential quantitative blood cultures in the diagnosis of catheter-related sepsis when this condition is suspected on clinical grounds and to establish a reliable discriminative value for application without removal of the inserted catheter. A total of 107 central venous catheters from 64 patients were used for the study. Blood was obtained simultaneously through the suspected infected device and from a peripheral venipuncture. The catheter was removed and its tip cultured semiquantitatively. Catheter-related sepsis occurred in 17 patients. Using as cut-off value a colony count fourfold higher in blood drawn through the catheter than in simultaneously drawn peripheral blood, a sensitivity of 94%, specificity of 100% and positive predictive value of 100% were obtained. A single bacterial count greater than 100 cfu/ml in the quantitative culture of the catheter blood specimen in the presence of a positive qualitative peripheral blood culture of the same organism was also highly suggestive of catheter-related sepsis. Differential quantitative blood culture is a reliable method for the diagnosis of catheter-associated sepsis without catheter removal.
BACKGROUND: A method of diagnosing catheter-related infection (CRI) without removing the catheter would be useful. An earlier positivity of central compared with peripheral venous-blood cultures may be associated with catheter-related bacteraemia. We evaluated prospectively the differential time to positivity (DTP) of paired blood cultures drawn simultaneously via the catheter hub and from a peripheral venous site. METHODS: Over a 14-month period in an intensive-care unit of a cancer referral centre, simultaneous hub-blood and peripheral-blood cultures (a mean of two per patient) were obtained from patients with a suspected CRI. According to clinical criteria and quantitative culture of the catheter tip, cases were classified as CRI or sepsis of other origin. At least one pair of hub-blood and peripheral-blood cultures was obtained within 48 h before catheter removal, and we recorded the DTP between hub-blood and peripheral-blood cultures with an automatic device for detection of blood culture positivity. FINDINGS: We analysed 93 catheters removed because of suspicion of CRI. In 28 episodes, the same micro-organisms were found in both hub-blood and peripheral-blood cultures. A diagnosis of definite bacteraemic CRI was made in 16 of the 17 patients in whom a positive hub-blood culture was detected at least 2 hours earlier than peripheral-blood culture. About half (9/17) of these episodes occurred in long-term (>30 days) devices. CRI was excluded in ten of the 11 patients with a DTP lower than 2 h. The DTP of paired blood cultures was significantly greater in patients with CRI than in others (p<10(-4)). A cut-off DTP value of 120 min had 91% specificity and 94% sensitivity for the diagnosis of CRI. Three of 17 episodes with only hub-blood culture positive were associated with CRI. INTERPRETATION: This prospective study suggests that measurement of the differential time to positivity between hub-blood and peripheral-blood cultures is a simple and reliable tool for in-situ diagnosis of catheter-related sepsis in cancer patients. Further studies are needed to confirm these data for short-term catheters.
To minimize pain when changing dressing for peripheral venous catheters, to select the adequate dressing in functions of the circumstances presented by each patient, and to utilize as references the recommendations by Centers for Disease Control and Prevention (CDCs) form the fundamental bases for this article.
Intravascular foreign bodies can cause significant complications: thrombosis, pulmonary and peripheral embolism, etc. It is therefore necessary to remove them, and this may be accomplished through surgery or by means of radiotherapy techniques. In the past year we have percutaneously extracted three foreign bodies originating in vascular access pathways.
BACKGROUND: Mitral valve surgery after previous coronary artery bypass grafting presents a challenging problem for the cardiac surgeon. An injury to patent coronary artery bypass grafts, especially internal mammary artery grafts, during reoperation via a redo sternotomy, may be fatal. Therefore, a reliable alternative to the redo sternotomy is desirable to minimize potential injury to internal mammary artery grafts. METHODS: Between February 1987 and October 1998, we performed 59 consecutive mitral valve operations after previous coronary artery bypass grafting surgery (CABG). A total of 24 patients (41%) had functioning internal mammary artery (IMA) grafts and represent the population for this study. No patients were excluded for any reason. Of the 24 patients, 20 (83%) were men. Mean age was 66+/-13 years (range 41 to 83 years) and the mean duration from CABG was 5.3+/-3.6 years (range 0.1 to 12 years). Four (17%) had functioning bilateral internal mammary artery grafts. All had 3 to 4+ mitral regurgitation (MR) at the time of mitral valve surgery and the mean preoperative ejection fraction (EF) was 40%+/-14% (range 20% to 74 %). RESULTS: Twenty-one (88%) patients underwent mitral valve surgery through an anterolateral right thoracotomy and 3 (12%) through a redo sternotomy. Twenty-two (92%) patients, including the 3 patients in whom a redo sternotomy was used, had cannulation of the femoral artery and vein. Two patients required axillary artery cannulation. All 21 patients in whom the mitral valve was approached through a right thoracotomy underwent deep hypothermia (19.6 degrees+/-2.1 degrees C, range 14 degrees to 25 degrees C) without aortic clamping, with a mean duration of CPB of 138+/-46 minutes (range 65 to 249 minutes). In 18 (75%), the MR was ischemic in origin and in 6 (25%) there was myxomatous degeneration. Nine (34%) required valve replacement and 15 (66%) underwent repair. There were no operative or hospital deaths and all patients were discharged to home or to a rehabilitation facility. There were 4 (17%) major complications. Two patients suffered respiratory failure requiring tracheotomy, 1 patient developed a perioperative MI requiring an intraaortic balloon pump and 1 developed heart block requiring a permanent pacemaker. There were no neurologic, peripheral vascular, bleeding, or wound complications. CONCLUSIONS: Reoperative mitral valve surgery in the setting of functioning IMA grafts, even in the face of depressed LV function, can be done safely and with minimal morbidity.
PURPOSE: We report our experience relative to transcatheter percutaneous embolization of post-biopsy renal intraparenchymal arteriovenous fistulas in patients with chronic renal insufficiency. MATERIAL AND METHODS: We observed 5 patients affected with post-bioptic fistulas for possible embolization. In three cases the symptoms were represented by intermittent macro-microhematuria; one patient had hypertension of nephrovascular origin and one patient was asymptomatic. In all cases we performed angiography and it was possible to catheterize the peripheral afferent branch of the fistula with a superselective technique using a hydrophilic guide of 0.035 F and a hydrophilic Cobra catheter of 4-5 F. The occlusion was obtained by the positioning of Granturco metal coils: in 1 case we adapted a coil of 3 mm diameter and 1 cm length; in 3 cases 2 coils of 3 mm and in 1 case 2 coils of 3 mm and 1 coil of 5 mm diameter and 1 cm length were necessary. The success of the procedure was always checked with an immediate angiogram and color Doppler US after 48 hrs. RESULTS: The diagnosis of arteriovenous fistulas was always confirmed by a preliminary angiography that demonstrated the normal anatomic disposition of the renal arteries except in one case in which the fistula was fed by a peripheral branch originating from an inferior polar artery. All the lesions were localized in the inferior pole, the site of biopsy, and ranged from 3 mm to 2.5 cm in diameter. We never had any difficulties in the positioning and placement of the coils. The arterial occlusion and exclusion of the fistula was accomplished in all cases. The induced parenchymal loss ranged from 10 to 30% of the renal volume. There was a complete disappearance of symptoms in 3 of the patients, with hematuria without any modification of the blood pressure values in the patient with hypertension. Considering the patient status renal function did not worsen after the embolization. Each patient was followed-up with color Doppler US every two months. CONCLUSIONS: The intrarenal arteriovenous fistula represents a relative frequent complication of renal needle biopsy in patients with arterial hypertension and nephroangiosclerosis as risk factors. Embolization is a valid alternative therapeutic option to surgical treatments. The use of small size catheters permits the successful embolization also of peripheral lesions, reducing the induced parenchymal ischemia. We believe that among the embolization material available metal coils represent a valid solution as they are easily positioned and permit definitive occlusion without any risks of systemic venous microembolization.
Venepuncture can be a painful and frightening experience for children. Nurses play an active role in helping them to cope with this experience and in reducing the adverse effects of venepuncture. This article explains how infants, children and their families can be supported and cared for before, during and after venepuncture.