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PubMed2002

Peroneal nerve palsy: a complication of umbilical artery catheterization in the full-term newborn of a mother with diabetes.

Umbilical artery catheters are an essential aid in the treatment of newborn infants who have cardiopulmonary disease. However, it is well-known that umbilical artery catheterization is associated with complications. The most frequent visible problem in an umbilical line is blanching or cyanosis of part or all of a distal extremity or the buttock area resulting from either vasospasm or a thrombotic or embolic incidence. Ischemic necrosis of the gluteal region is a rare complication of umbilical artery catheterization. We report the case of a full-term infant of an insulin-dependent diabetic mother with poor blood glucose control who developed a left peroneal nerve palsy after ischemic necrosis of the gluteal region after umbilical artery catheterization. The infant was born weighing 5050 g. The mother of the infant had preexisting diabetes mellitus that was treated with insulin from the age of 14 years. The metabolic control of the mother had been unstable both before and during the pregnancy. The neonate developed respiratory distress syndrome soon after birth and was immediately transferred to the neonatal intensive care unit. Mechanical ventilation via endotracheal tube was quickly considered necessary after rapid pulmonary deterioration. Her blood glucose levels were 13 mg/dL. A 3.5-gauge umbilical catheter was inserted into the left umbilical artery for blood sampling without difficulty when the infant required 100% oxygen to maintain satisfactory arterial oxygen pressure. Femoral pulses and circulation in the lower limbs were normal immediately before and after catheterization. A radiograph, which was taken immediately, showed the tip of the catheter to be at a level between the fourth and fifth sacral vertebrae. The catheter was removed immediately. Circulation and femoral pulses were normal and no blanching of the skin was observed. Another catheter was repositioned and the tip was confirmed radiologically to be in the thoracic aorta between the sixth and seventh thoracic vertebrae. The catheter was continuously flushed with heparinized solution. Three days after umbilical arterial catheterization, bruising was observed over the left gluteal region. The catheter was immediately removed despite its correct position. Over the next few days, the bruised skin and underlying tissues became necrotic. The area affected was 3 x 4 cm in diameter, with central necrosis surrounded by a rim of dark, red skin, which, in turn, was sharply demarcated from normal skin by a narrow, pale zone. Surgical excision of the gluteal necrosis was performed, but a deep ulcer 3 cm in diameter was left. The gluteal ulcer required 1 month to heal completely with extensive scar tissue formation. Throughout this period, the infant showed active movements in all of her limbs. At 4 weeks of age deterioration of all movement below the left knee with a dropping foot was observed. Severe peroneal nerve palsy was confirmed through nerve conduction studies, and there was electromyographic evidence of degeneration of the muscles supplied by the peroneal branch of the sciatic nerve. A Doppler study, which was also conducted, revealed no vascular damage. Treatment with physiotherapy and night-splinting of the left ankle was instituted. Repeated examination and nerve conduction tests at 3 months showed slow improvement with the left peroneal nerve remaining nonexcitable. At the time of this writing, the infant is 6 months old, and muscular strength below the left knee is still weak and atrophic changes in the form of muscle-wasting are already present. The rest of her motor development is normal. In our case, gangrene of the buttocks and sciatic nerve palsy followed displacement of the tip of the catheter into the inferior gluteal artery, a main branch of the internal iliac artery supplying the gluteus maximus, the overlying skin, and the sciatic nerve. The gangrenous changes were probably caused by vascular occlusion resulting from catheter-induced vasospasm of the inferior gluteal artery. Sciatic nerve palsy associated with umbilical artery catheterization has been postulated to be caused by vascular occlusion of the inferior gluteal artery. Infants of diabetic mothers may exhibit changes in coagulation factors and be at increased risk of thrombotic complications in utero and postnatally. In addition, maternal diabetes mellitus is associated with an increased incidence of congenital abnormalities, the incidence of which is 3 to 5 times higher than that among nondiabetic mothers. Although no particular or specific abnormalities have been associated with maternal disabilities, abnormalities of the cardiovascular system, including the development of umbilical vessels, frequently occur. This complication of umbilical artery catheterization has not been widely reported. We describe the first case that refers to gluteal gangrene and peroneal nerve palsy after umbilical artery catheterization of a newborn infant of a diabetic mother with poor blood glucose control. It should be noted that there were no contributing factors except that of the displacement of the catheter into the inferior gluteal artery. We speculate that the displacement of the tip of the catheter, with no difficulty in the present case, was associated with the maldevelopment of normal branching patterns of arteries after exposure of the fetus to hyperglycemia. In conclusion, umbilical artery catheterization is possibly associated with vascular occlusion, particularly in infants of diabetic mothers. Frequent inspection after the procedure has been performed is of the utmost importance especially in these neonates who often suffer from cardiopulmonary disease and require catheterization of their umbilical artery.

Buttocks↗

PubMed2002

Sex differences in cardiac catheterization after acute myocardial infarction: the role of procedure appropriateness.

BACKGROUND: Many studies have found that women are less likely than men to have cardiac catheterization after an acute myocardial infarction; however, it is unknown whether sex differences reflect inappropriate treatment. OBJECTIVE: To ascertain whether cardiac catheterization use after acute myocardial infarction in men and women varied by sex and the appropriateness of the procedure, as determined by clinical guidelines. DESIGN: Retrospective analysis of chart-abstracted data. SETTING: U.S. acute-care hospitals. PATIENTS: 143 444 Medicare patients who were hospitalized for acute myocardial infarction between 1994 and 1996. MEASUREMENTS: Cardiac catheterization use within 60 days of hospitalization for acute myocardial infarction. RESULTS: Women had lower crude rates of cardiac catheterization than men (35.7% for women vs. 46.5% for men [ P < 0.001]; difference, 10.8 percentage points). Multivariable adjustment for demographic, clinical, and hospital characteristics reduced most of the sex differences in procedure use (risk-standardized rates, 40.3% for women vs. 41.9% for men [ P < 0.001]; difference, 1.6 percentage points). Sex differences in cardiac catheterization use varied by the appropriateness of the procedure. Risk-standardized rates of cardiac catheterization were similar for men and women with strong indications for the procedure (44.1% for women vs. 44.6% for men [ P > 0.2]; difference, 0.5 percentage point). Rates of cardiac catheterization use among patients with weak indications did not significantly differ between men and women (16.5% for women vs. 18.0% for men [ P = 0.096]; difference, 1.5 percentage points). Sex differences in cardiac catheterization use were largest for patients with equivocal indications (39.4% for women vs. 42.5% for men [ P < 0.001]; difference, 3.1 percentage points). CONCLUSIONS: Among elderly persons, women have lower rates of cardiac catheterization use after an acute myocardial infarction than men. However, this difference was attenuated after multivariable adjustment, and it occurred primarily in patients with equivocal indications. We found no sex variations in procedure use among patients who had strong indications for cardiac catheterization.

Aged↗

PubMed1994

[Quality management in the heart catheterization laboratory].

Quality management within the catheterization laboratory includes the quality control, the heart catheterization technique and the policy. Quality management is critical in the heart catheterization laboratory. Dedication of all members of the lab and computer personnel ensures high patient satisfaction. A continued quality improvement program is patient-orientated and requires good planning. One of the main emphasis in the catheterization lab is standardization which includes the patient preparation, the procedure itself, and the management. It is supported by teamwork including the economic aspect of prompt delivery of material and avoidance of complications. A continuous circle of treatment planes, performance, and check is regarded as the Deming cycle and leads to continuous improvement of quality. Important are both the avoidance and detection of complications. The reasons for any such have to be evaluated. It is recommended to follow the zero mistake hypothesis of Crosby, which means quality control by the lab supervisor, a quality consciousness, a quality measurement and quality improvement, as well as using a day to day quality improvement and to teach quality control. In Germany a quality control questionnaire was administered in an analysis of the current structure, function, and results of catheterization labs. Most important was the analysis of complications. The data were based on diagnostic catheterization in 1992, which included 140668 catheterizations in 83 laboratories. Thus, a mean of 1030 heart catheterizations was performed in each lab. In the mean, 200 catheterizations were performed by each doctor. In 19% of the labs digital imaging was exclusively performed. Major complications occurred with ventricular fibrillation in 0.36% (range 0.75%), resuscitation 0.18% (0.43%), persistent cerebrovascular accident 0.08% (0.24%), myocardial infarcts 0.19% (0.59%), aortic dissection 0.05% (0.22%). Mortality was 0.03% (0.08%). In heart catheterization laboratories quality management is one of the major goals for the future work. Only the continued improvement of quality and very good quality management ensure patient safety. Quality is the sum of technique and consciousness.

Cardiac Catheterization↗

PubMed2001

Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial.

CONTEXT: Whether venous catheterization at the femoral site is associated with an increased risk of complications compared with that at the subclavian site is debated. OBJECTIVE: To compare mechanical, infectious, and thrombotic complications of femoral and subclavian venous catheterization. DESIGN AND SETTING: Concealed, randomized controlled clinical trial conducted between December 1997 and July 2000 at 8 intensive care units (ICUs) in France. PATIENTS: Two hundred eighty-nine adult patients receiving a first central venous catheter. INTERVENTIONS: Patients were randomly assigned to undergo central venous catheterization at the femoral site (n = 145) or subclavian site (n = 144). MAIN OUTCOME MEASURES: Rate and severity of mechanical, infectious, and thrombotic complications, compared by catheterization site in 289, 270, and 223 patients, respectively. RESULTS: Femoral catheterization was associated with a higher incidence rate of overall infectious complications (19.8% vs 4.5%; P<.001; incidence density of 20 vs 3.7 per 1000 catheter-days) and of major infectious complications (clinical sepsis with or without bloodstream infection, 4.4% vs 1.5%; P =.07; incidence density of 4.5 vs 1.2 per 1000 catheter-days), as well as of overall thrombotic complications (21.5% vs 1.9%; P<.001) and complete thrombosis of the vessel (6% vs 0%; P =.01); rates of overall and major mechanical complications were similar between the 2 groups (17.3% vs 18.8 %; P =.74 and 1.4% vs 2.8%; P =.44, respectively). Risk factors for mechanical complications were duration of insertion (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.08 per additional minute; P<.001); insertion in 2 of the centers (OR, 4.52; 95% CI, 1.81-11.23; P =.001); and insertion during the night (OR, 2.06; 95% CI, 1.04-4.08; P =.03). The only factor associated with infectious complications was femoral catheterization (hazard ratio [HR], 4.83; 95% CI, 1.96-11.93; P<.001); antibiotic administration via the catheter decreased risk of infectious complications (HR, 0.41; 95% CI, 0.18-0.93; P =.03). Femoral catheterization was the only risk factor for thrombotic complications (OR, 14.42; 95% CI, 3.33-62.57; P<.001). CONCLUSION: Femoral venous catheterization is associated with a greater risk of infectious and thrombotic complications than subclavian catheterization in ICU patients.

Catheterization, Central Venous↗

PubMedDate not supplied

Variability between methods of calculating mitral valve area: simultaneous Doppler echocardiographic and cardiac catheterization studies conducted before and after percutaneous mitral valvuloplasty.

The purpose of this study was to assess the variability of measuring the mitral valve area (MVA) by the cardiac catheterization (Gorlin) method and two Doppler echocardiographic methods, the pressure half-time and continuity equation methods. The determinants of MVA were measured simultaneously before and after percutaneous mitral balloon valvuloplasty (PBMV). Thirty-three patients with severe mitral stenosis underwent simultaneous measurements of MVA by the three methods immediately before and within 15 minutes after PBMV. After combining all data, the correlation between the catheterization and pressure half-time methods was significant (r = 0.65; p < 0.001), as was that between the catheterization and continuity equation methods (r = 0.64; p < 0.001). However, there was a large degree of variability among the measurements with the three techniques. The mean difference between the catheterization and pressure half-time methods of measuring MVA before PBMV was -0.2 +/- 0.4 cm2 and 0.1 +/- 0.3 cm2 between the catheterization and continuity equation methods. This variability was even more marked after PBMV: -0.5 +/- 0.9 cm2 between the catheterization and pressure half-time methods and 0.4 +/- 0.6 cm2 between the catheterization and continuity equation methods. Although previous studies have shown a good correlation between MVA as measured with the catheterization and two Doppler echocardiographic methods, they included a wide range of MVAs. In our study of patients with hemodynamically significant mitral stenosis, there was a large degree of variability between the catheterization and simultaneously performed Doppler echocardiographic methods. The calculated MVA by any method should not be used as the single measure of severity of stenosis.

Adult↗

PubMed1994

Mobile cardiac catheterization registry: report of the first 1,001 patients.

The purpose of this study was to evaluate prospectively the efficacy and safety of mobile cardiac catheterization. Mobile cardiac catheterization was introduced into clinical practice in 1989, but there has been no systematic study of its performance and safety. A registry was established in 1989 to monitor outcomes with mobile cardiac catheterization and is reported here. Patients were screened for eligibility for mobile cardiac catheterization using the joint AHA/ACC criteria for outpatient angiography. Eligible patients underwent mobile catheterization at eight hospitals within 120 miles of the base tertiary center. Helicopter evacuation services were available at each mobile site. The indications, findings, dispositions, and complications of mobile cardiac catheterization were recorded by means of a checklist, telephone follow-up and chart review. A total of 1,001 consecutive patients were entered into the registry in the first 20 months of operation, including 436 females and 565 males aged 22 to 84 years. Angina (Canadian Classes II-IV) was the most frequent primary indication for catheterization (46.4%), followed by atypical chest pain (36.9%), or a positive exercise stress test (25.6%). Infrequent indications for catheterization included a history of myocardial infarction (5.6%), congestive heart failure (7.1%), arrhythmias (4.1%), and valvular heart disease (0.7%). Catheterization was accomplished in 99.9% of patients. Angiographically normal studies were observed in 22.8%, and mild (< or = 50%) coronary artery disease in 13.6% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1996

Postoperative catheterization, urinary retention, and permanent voiding dysfunction after polytetrafluroethylene suburethral sling placement.

OBJECTIVE: To determine the incidence of permanent voiding dysfunction after polytetrafluoroethylene suburethral sling placement, and to assess the effect of voiding mechanism and uroflowmetry on the duration of postoperative catheterization. METHODS: Between January 1986 and April 1991, 108 patients underwent suburethral sling procedures to treat genuine stress incontinence. Medical records were reviewed to collect urodynamic and catheterization data. One year or longer after surgery, 98 women completed a telephone interview evaluating incontinence, self-catheterization, and voiding symptoms. RESULTS: The mean duration of postoperative cathtrerization was 10.7 weeks. There was no significant relationship between preoperative uroflow indices and the duration of catheterization. The presence of a preoperative detrusor contraction was associated with a shorter mean duration of postoperative catheterization (6.1 versus 14.8 weeks, P = .07) and a lower risk of sling removal for retention (7 versus 33%, P = .04). Eight patients continued self-catheterization. Fourteen patients reported other micturition problems: three used the Credé maneuver or double voided to facilitate emptying and 11 were unable to urinate when seated upright. There was no correlation between the duration of catheterization and ongoing voiding dysfunction. Among nine women who underwent further surgery to treat postoperative urinary retention, three continue to catheterize, one performs Credé, and one urinates standing. CONCLUSIONS: Polytetrafluoroethylene suburethral sling placement commonly produces permanent voiding difficulty. Patients who void without a detrusor contraction are at increased risk for prolonged postoperative catheterization. Sling removal does not ensure resolution of urinary retention and may be no better than leaving the sling in place.

Adult↗

PubMed2004

Should we cross the valve: the risk of retrograde catheterization of the left ventricle in patients with aortic stenosis.

CLINICAL SCENARIO: A 67-year-old man is referred to your cardiology clinic complaining of worsening angina and dyspnea on exertion. Physical examination reveals a harsh grade IV/VI late-peaking crescendo-decresendo systolic murmur, loudest at the upper sternal border. The aortic closure sound is diminished. Echocardiography demonstrates left ventricular hypertrophy, an ejection fraction of 50%, no evidence of mitral regurgitation, and severe aortic stenosis (AS) with a peak aortic gradient of 4.8 m/s (92 mm Hg) and a mean aortic gradient of 55 mm Hg. You schedule him for coronary angiography but wonder whether you should reevaluate his aortic valve gradient invasively. LITERATURE SEARCH: Combining the keywords "aortic valve stenosis" and "heart catheterization/adverse effects," you find 72 articles. From these you choose the following: Omran H, Schmidt H, Hackenbroch M, et al. Silent and apparent cerebral embolism after retrograde catheterization of the aortic valve in valvular stenosis: a prospective randomized study. Lancet 2003;361:1241-6. QUESTION: What is the stroke risk of retrograde catheterization of the aortic valve in patients with AS? DESIGN: The study was prospective and randomized; unblinded treatment but with blinded assessment of outcomes. SETTING: The study was conducted at a single center in Bonn, Germany. PATIENTS: A total of 152 patients with known or suspected AS undergoing cardiac catheterization were randomized to catheterization with or without retrograde passage of the aortic valve in a 2:1 randomization format. Patients underwent brain magnetic resonance imaging (MRI) the day before and within 48 hours after cardiac catheterization. Patients with unclear echo findings or contraindications to MRI or transesophageal echocardiography were excluded. There were no significant baseline differences between the 2 groups: mean age 70.5 years, left ventricular ejection fraction 62%, and mean aortic valve gradient 51 mm Hg. All patients were evaluated in the groups to which they had been randomized and, other than the experimental intervention, the 2 groups were treated similarly (with the exception of the administration of 5000 units of intravenous heparin to the group receiving retrograde aortic catheterization). A control group of 32 patients without aortic valvular stenosis was evaluated as well. INTERVENTION: The intervention consisted of retrograde passage of the aortic valve for the purpose of obtaining an invasive aortic valve pressure gradient. MAIN OUTCOME MEASURES: The main outcome measures were acute cerebral embolic events, defined by MRI findings within 48 hours after catheterization (as compared to precatheterization MRI) and by clinical examination. MAIN RESULTS: Twenty-two of 101 patients (22%) assigned to retrograde catheterization developed new focal MRI abnormalities consistent with acute cerebral embolic events. Three of these patients (3%) demonstrated clinically apparent neurologic deficits. None of the patients who did not undergo retrograde catheterization--and none of the control patients--had MRI or clinical evidence of cerebral embolism.

Aged↗

PubMed2006

Echocardiography versus right-sided heart catheterization among lung transplantation candidates.

BACKGROUND: Right-heart-catheterization and transthoracic echocardiography are routine tests to measure pulmonary artery systolic pressure among lung transplantation candidates. Echocardiography may be as accurate as right-heart-catheterization, without the inherent risks of an invasive test. METHODS: We examined the correlation between pulmonary pressures estimated by echocardiography versus right-heart-catheterization among lung transplantation candidates and their correlation to measurements during lung transplantation. Our cohort included all lung transplantation candidates during 1997 through 2004 who initially underwent pulmonary pressure evaluation by right-heart-catheterization and echocardiography, as well as measurements during lung transplantation. RESULTS: Of the 106 candidates, evaluation by transthoracic echocardiography was possible in 79 (74.5%). Median pulmonary systolic pressures by right-heart-catheterization was 44.0 [33.2-50.0] mm Hg and by echocardiography 40.0 [32.5-51.5] mm Hg (r = 0.80, p < 0.0001). In 14 (17.7%) patients the difference between the 2 methods was > 20 mm Hg. The median time interval between echocardiography and right-heart-catheterization was 65 [40-155] days. The median value of pulmonary systolic pressure measured during lung transplantation in 44 (70.1%) of 62 patients was 39.5 [31.0-50.0] mm Hg. The time interval right-heart-catheterization-to-lung transplantation was 143 [87-339] days and echocardiography-to-lung transplantation 229 [130-367] days. The correlation between measurements during lung transplantation and initial measurements by right-heart-catheterization and echocardiography were r = 0.50 and r = 0.31, respectively, with corresponding p values of p = 0.001 and p = 0.07. CONCLUSIONS: For lung transplantation candidates and a suitable transthoracic echocardiography estimate of pulmonary systolic pressure, the need for right-heart catheterization, with its inherent risks for complications, may be foregone. The weak correlation between the initial and intraoperative measurements, probably stemming from the significant time interval, suggests that serial measurements may be needed.

Cardiac Catheterization↗

PubMed1977

Intermittent catheterization and vesical defenses.

The effectiveness of intermittent catheterization in eradicating bacteriuria in patients requiring catheterization for inadequate voiding was subjected to a mathematical analysis to establish its theoretical basis. It can be shown that, at 1 extreme, with 6 ml. urine remaining in the bladder, assuming reasonable hydration, catheterization must be done at least every 2 to 2 1/2 hours to limit bacteriuria. In contrast, if as little as 0.5 ml. urine is left behind, catheterization may be done every 4 to 5 hours to achieve the same result. Moreover, from the graphic depiction of the calculation it is seen that a reduction in the intervals between catheterization has a much greater effect than an increase in the urinary output in the reduction of the bacterial count. The volume of residual urine after catheterization was directly determined by measurement of phenolsulfonphthalein that was washed out after drainage by catheter in the female dog and in women. In the dog it averaged 0.435 ml. but in women it was somewhat greater than that after normal voiding. Upon applying the equation relating frequency of catheterization and urinary output to residual urine in a clinical program of intermittent catheterization, we found that the usual (convenient) schedule often resulted in showing that an unattainably small volume of urine would have to be left in the bladder. Actual measurement of residual urine by the modified phenolsulfonphthalein test provides the data needed to design a program of intermittent catheterization for each patient that will lead to urinary sterility.

Animals↗

PubMed1998

Effect of intermittent urethral catheterization and oxybutynin bladder instillation on urinary continence status and quality of life in a selected group of spinal cord injury patients with neuropathic bladder dysfunction.

OBJECTIVES: A comparative assessment of (i) urinary continence status, (ii) quality of life, and (iii) sexuality in spinal cord injury patients prior to, and during intermittent catheterization with adjunctive intravesical oxybutynin therapy (Cystin: manufactured by Leiras Oy. Helsinki, Finland). SETTING: A hospital, and community-based study of selected adult, male, spinal cord injury patients registered with the Regional Spinal Injuries Centre, Southport. PATIENTS: Seven patients (mean age: 44.3 years) suffering from neuropathic bladder due to suprasacral spinal cord lesion of traumatic aetiology, and well settled in the community in the north-west of England were the subjects of this study. Before commencing the intermittent catheterization regime, these patients were on penile sheath drainage. INTERVENTION: Intermittent urethral catheterization was performed with sterile, single-use Nelaton catheters 5-6 times a day with intravesical instillation of oxybutynin 5 mg in 30 ml. 1-3 times a day for periods ranging from 14 to 30 months. OUTCOME MEASURES: Assessment of urinary continence, sexuality, and quality of life was made (i) at the outset before any intervention, (ii) during intermittent catheterization regime, and (iii) when the patients were using the oxybutynin bladder instillation along with intermittent catheterization. RESULTS: Initially all the seven patients were constantly wearing penile sheaths and leg bags. When these patients performed intermittent catheterization 5-6 times in 24 h, they attempted to discard the penile sheath during the day but they were experiencing mild to moderate urine leak between catheterization. They were compelled to wear penile sheaths during night. Subsequently, five patients took oxybutynin by mouth, but developed an unacceptable degree of side-effects necessitating discontinuation of the medication. Following commencement of intravesical oxybutynin therapy, all of them were able to discard the penile sheaths and leg bags during the day as well as during the night. However, on waking-up after a full night's sleep, three patients found dampness of their undergarments 1-2 times per week. None of the patients experienced side-effects attributable either to the intermittent catheterization procedure, or to the intravesical oxybutynin therapy. The number of episodes of urinary infection requiring antibiotic therapy was 0.08/patient/month. All the seven patients noticed a remarkable improvement in the quality of life because they had achieved a high degree of continence. All the seven patients commented on the improved sense of their own sexuality which was attributed to (i) absence of incontinence episodes, (ii) improved self-image, and (iii) not wearing penile sheaths and leg bags. CONCLUSION: These seven spinal cord injury patients achieved socially acceptable continence with improved quality of life, and enhanced sexuality with the intermittent urethral catheterization regime and intravesical oxybutynin therapy.

Adult↗

PubMed1994

Complications and failures of subclavian-vein catheterization.

BACKGROUND: Although catheterization of the subclavian vein is a common procedure, the risk factors for complications and failures, with the exception of the physician's experience, are poorly understood. Ultrasonography has been recommended to help guide the placement of central venous catheters. METHODS: We conducted a prospective randomized trial of ultrasound-guided location of the subclavian vein as compared with standard insertion procedures. In the group of patients undergoing catheterization with ultrasound guidance, the site of the insertion was marked before the catheterization attempt; real-time ultrasound guidance was not used. The 821 eligible patients (411 in the ultrasound group and 410 in the control group) underwent catheterization in a single procedure suite under controlled nonemergency conditions, in most cases for the administration of chemotherapy. RESULTS: Ultrasound guidance had no effect on the rate of complications or failures of subclavian-vein catheterization (risk ratio for complications, 1.00; 95 percent confidence interval, 0.66 to 1.52; risk ratio for failures, 1.04; 95 percent confidence interval, 0.72 to 1.50). In multivariate analyses, prior major surgery in the region (P = 0.002), a body-mass index (the weight in kilograms divided by the square of the height in meters) higher than 30 or lower than 20 (P = 0.009), and previous catheterization (P = 0.043) were associated with failed attempts. Complications were also associated with failed attempts: 52 of the 721 patients (7.2 percent) in whom catheterization was successful had complications, as compared with 28 of the 100 patients (28 percent) in whom physicians were unable to place catheters. The number of needle passes was strongly associated with the rates of failure and complications. The complication rate rose from 4.3 percent with one pass to 24.0 percent with more than two passes. CONCLUSIONS: Ultrasound guidance of subclavian-vein catheterization, as used in this study, was not beneficial. In patients at highest risk for complications and failures, catheterization should be attempted by the most experienced physicians available.

Body Mass Index↗

PubMed1998

Pulsed Doppler ultrasonography guidance for catheterization of the subclavian vein: a randomized study.

BACKGROUND: Catheterization of the subclavian vein may lead to severe complications. The current randomized study compared a technique of pulsed Doppler ultrasonography guidance and the standard method for subclavian vein catheterization. METHODS: Standard and Doppler ultrasonography guidance methods were performed by the same physician in 286 patients, 143 in each group. Primary end points were immediate complications (arterial puncture, pneumothorax, wrong position of catheter tip), failures, the number of subclavian vein catheterizations with immediate complication or failure, the number of skin punctures per catheterization, and the time to placement of the guide wire. The secondary end points were the determination of predicting factors of successful cannulation in each group. RESULTS: Both groups were similar according to morphologic parameters of the patients. A greater number of subclavian vein catheterizations were performed on the right side using Doppler guidance (105 vs. 73, P < 0.01). Doppler guidance decreased complications (5.6% vs. 16.8%, P < 0.01), largely because of a smaller number of catheters for which the tip was defined to be in incorrect position (0.7% vs. 7.7%, P < 0.01). The time to catheterization was longer with Doppler guidance (300 vs. 27 s, P < 0.001). Failures, catheterizations of the subclavian vein with immediate complications or failure, and the total number of skin punctures per catheterization were similar in both groups. Using Doppler guidance, the presence of a good Doppler signal (124 of 143) was predictive of successful catheterization (123 successful cannulations, P < 0.001). CONCLUSIONS: Doppler guidance reduces the incidence of inappropriately positioned subclavian catheters.

Adult↗

PubMed1984

Clinical evaluation compared to pulmonary artery catheterization in the hemodynamic assessment of critically ill patients.

Although pulmonary artery (PA) catheterization is frequently employed in the management of critically ill patients, there is little documentation that the information obtained alters patient management. This study evaluated prospectively this question in 103 PA catheterizations. Before catheterization, physicians were asked to predict the range of several hemodynamic variables, the presumed diagnosis, and their plan for therapy. After catheterization, each chart was reviewed. The hemodynamics at the time of catheterization and therapy within 8 h of catheterization were noted. Pulmonary artery occlusive (wedge) pressure (WP) was correctly predicted 30% of the time. Cardiac output, systemic vascular resistance (SVR), and right atrial pressure (RAP) were correctly predicted approximately 50% of the time. There was no significant difference in the ability to predict hemodynamics of subgroups with either hypotension or impaired oxygenation. After catheterization, planned therapy was altered in 58% of the cases. Unanticipated therapy was added in 30% of the cases. This study documents the difficulty of predicting accurately hemodynamics based solely on clinical evaluation. Thus, the information obtained by catheterization often leads to alterations in the therapeutic plan. We suggest that PA catheterization is both indicated and useful in the management of critically ill patients.

Blood Pressure↗

PubMed2005

Incidents and complications during pediatric cardiac catheterization.

BACKGROUND: Cardiac catheterization has revolutionized the management of pediatric cardiac disease. There has been little information on adverse events during these cases from an anesthesia viewpoint. The aim of this audit was to determine the incident rate during pediatric cardiac catheterization as contemporaneously reported by the anesthetist and to identify both the types of events and which procedures had the highest risk. METHODS: Since 1993, data have been collected prospectively on an audit form for every anesthetic given in our institution, and in-theatre events were recorded on this form. We have reviewed the data collected on pediatric cardiac catheterizations over a period of 9 years. RESULTS: A total of 4454 cardiac catheterizations were recorded. The overall incidence of events was 9.3%. Cardiac catheterization with occlusion of a patent ductus arteriosus (PDA) or a secundum atrial septal defect (ASD) had the lowest event rate at 4.2%. The figure for cardiac catheterization with other therapeutic interventions was 11.6 and 9.3% for solely diagnostic cardiac catheterization. The event rate in infants under the age of 1 year was 13.9% compared with 6.7% for those children over the age of 1 year. Of the 253 reports from cardiac catheterizations that could be analyzed further, there were 91 major complications including four deaths, 72 minor complications and 90 other incidents. CONCLUSIONS: Adverse events occur more commonly during cardiac catheterization than during pediatric anesthesia in general. Cases with highest risk are those in the under 1 year olds and those including a therapeutic intervention other than PDA or ASD occlusion.

Cardiac Catheterization↗

PubMed1985

Is bladder catheterization really necessary before laparoscopy?

A randomized prospective controlled trial compared a policy of bladder catheterization with no catheterization in patients undergoing laparoscopy. Of the 41 patients randomized to receive no catheterization, seven were actually catheterized on the judgement of the surgeon, but only one of them had greater than 50 ml of urine. Midstream urine obtained 6 days after laparoscopy was infected in 9 (21%) of the 42 patients allocated to receive catheterization and in only five (12%) of those allocated to the no-catheter group. Four of these five were actually not catheterized, giving an infection rate of 12% in the 34 patients not catheterized. The differences are statistically significant. A routine policy of catheterization for patients undergoing laparoscopy is questionable. All patients who are catheterized should be investigated for urinary tract infections after operation.

Adult↗

PubMed1995

Clean intermittent catheterization: safe, cost-effective bladder management for male residents of VA nursing homes.

OBJECTIVES: To compare the safety and cost of clean versus sterile intermittent bladder catheterization in male nursing home residents. To provide evidence to support the hypothesis that intermittent catheterization is a valid, alternative method of bladder management in male residents of long-term care in whom urinary retention is a documented problem. DESIGN: Randomized clinical trial. SETTING: Three long-term care sites having predominantly male populations. PARTICIPANTS: Eighty male veterans, residents of three long-term care facilities, ranging in age from 36 to 96 years with a mean age of 72. INTERVENTIONS: Standardized procedures for clean and sterile intermittent catheterization (IC) were implemented by staff nurses at each site. Patients were randomized into clean and sterile IC groups. Nursing time and catheterization equipment usage were recorded using bar code readers. Clinical data were collected from the medical chart. Treatment of urinary tract infection was prescribed by the medical personnel responsible for each individual resident. MEASUREMENTS: We compared the number of treatment episodes for symptomatic bacteriuria between groups randomized to receive either clean or sterile intermittent catheterization. Laboratory analysis of blood and urine was done on predetermined days. Control variables were research site and patient history of urinary tract infection within the last 6 months. A cost comparison of nursing time and equipment usage for the two catheterization techniques was also performed. RESULTS: No significant differences were found between clean and sterile groups with regard to number of treatment episodes, time to first infection, type of organism cultured, or cost of antibiotic treatment. The cost of sterile technique was considerably higher both in terms of nursing time and supplies. CONCLUSIONS: Findings from this study demonstrate that clean technique intermittent catheterization is a safe and cost-effective bladder management technique with male, nursing home residents, despite the frailty of this high risk population. An annual savings of approximately $1460 per patient in nursing time and catheterization supplies could be anticipated if a patient were catheterized an average of four times per day substituting clean IC technique for sterile IC technique.

Adult↗

PubMed2000

Cardiogenic shock: single center experience with and without on-site catheterization facilities.

BACKGROUND: The beneficial effect of on-site catheterization facilities on the survival of all patients with myocardial infarction complicated by cardiogenic shock has been questioned. Our objective was to evaluate the impact of the availability of on-site catheterization facilities on the outcome of unselected patients with cardiogenic shock. METHODS AND RESULTS: We studied the hospital records of 70 consecutive patients with cardiogenic shock admitted to our intensive coronary care unit during 1990-1996, and compared two groups of patients: those admitted before (n = 34) and after (n = 36) the opening of our catheterization laboratory. Patients admitted when the catheterization laboratory was available were of similar age, but included fewer males and fewer patients with prior myocardial infarction. Following the activation of the catheterization laboratory, utilization rates of coronary angiography, percutaneous transluminal coronary angioplasty and intra-aortic balloon pump increased, compared with the previous period. However, there was no improvement in in-hospital (88 vs. 83%; p = 0.7) and 30-day mortality (91 vs. 86%; p = 0.7) before versus after the activation of our catheterization laboratory. Twelve patients selected to cardiac catheterization (9 underwent percutaneous transluminal coronary angioplasty) experienced lower in-hospital and 30-day mortality compared with patients who were not selected (58 vs. 96, and 67 vs. 96%, respectively; p < 0.02). CONCLUSIONS: Following the activation of the catheterization laboratory, the mortality of the entire population of cardiogenic shock patients remained relatively unchanged. Still, a small subgroup of these patients selected for urgent cardiac catheterization had a lower mortality compared with patients who were not selected.

Aged↗