Accidental Arterial Puncture Research Articles

Study on Unguided Temporary Pacing Via the Jugular Vein at the Mohamed VI University Hospital of Marrakech: Safety, Effectiveness and Practicability

This study evaluates the safety, effectiveness, and feasibility of unguided temporary pacemaker insertion in 348 patients at the Mohamed VI University Hospital of Marrakech. The procedure was performed by cardiology residents and showed a high success rate of 99.71%, with successful access to the right internal jugular vein in 89.66% of cases. The majority of patients (66.38%) achieved venous access on the first attempt, with an average procedure time of 11.5 ± 2.1 minutes. Minor complications were observed in 10.63% of patients, including local hematomas (3.45%), accidental arterial punctures (2.30%), pneumothorax (1.15%), and other issues such as local infections and non-sustained ventricular tachycardia. No deaths attributable to the procedure were reported. The clinical significance of this study lies in its demonstration that unguided temporary pacemaker insertion is a safe and effective alternative in resource-limited settings, reducing treatment delays and potentially lowering mortality among patients requiring temporary cardiac pacing. Based on these results, it is recommended to encourage clinicians in primary and secondary healthcare settings to adopt this approach to improve access to urgent cardiac care in under-resourced regions.

Practice Guidelines for Central Venous Access 2020 - Time for German Guidelines

The American Society of Anesthesiologists released practice guidelines for central venous access in 2020, and the entire world literature was examined for evidence on how to perform the entire process with best practice and minimal risk and harm to the patient. These guidelines may serve as a gold standard for individual procedural steps, allowing practitioners and hospital departments to critically question the own standard and improve upon them.We interpreted the guidelines for individual procedural steps on how to improve success of catheterization, minimize risks or adverse effects, enhance the management of accidental arterial punctures, adhere to evidence-based practices, and generally reduce the trauma of puncturing. In our opinion, the most needed recommendation for central venous access is to utilize ultrasound guidance, a practice that many international societies have already incorporated into their published national guidelines.In our view, it is time to implement a national guideline for central venous access using ultrasound in Germany. Doing so may improve success rates in the first attempt, reduce procedural time, decrease the number of needle insertions per patient, and lower the rate of arterial punctures. This approach represents best practice from ethical, insurance, civil rights, and patient security perspectives, and is supported by relevant societies.

Systematic application of SICA-PED protocol for central venous catheterization in neonates: A prospective clinical study on 104 cases.

Catheterization of central vessels can be associated with early and late, potentially fatal complications. A proactive approach is imperative to reduce the frequency and magnitude of adverse events. Recently, the GAVeCeLT has proposed a protocol called SICA-PED (i.e. Safe Insertion of Central Access in Pediatric patients) and includes seven evidence-based strategies. Through a single-center prospective observational study, the authors wanted to consolidate the efficacy and safety of these protocol in newborns. In a series of 104 newborns, the seven steps of the protocol were applied (1) pre-procedural ultrasound study of the RaCeVA veins, (2) correct aseptic technique, (3) ultrasound-guided venipuncture, (4) intraprocedural localization of the tip of the catheter with TTE (ECHO TIP) and (iECG) intracavitary electrocardiogram, (5) reasoned choice of the implant exit site with the RAVESTO Tunneling technique, (6) anchoring without stitches, and (7) exit point protection with the use of glue and transparent semipermeable membrane. The authors have included a further precaution in point (6) the subcutaneous anchoring system has added the counter-fixation of the catheter wings that we will call 6Plus Point. All infants requiring implantation of elective us-guided central venous access were enrolled in the study. None of the 104 implanted central venous catheters experienced early complications (accidental arterial puncture, PNX, primary malposition); rare late complications such as ecchymosis, CRBSI, exit site infection or dislodgement were observed, No catheter-related thrombotic phenomena were observed. The CRBSI catheter-related infection rate was 2.47 × 1000 days catheter cases. The results of this prospective study strengthen the feasibility and efficacy of the SICA-Ped Protocol. Demonstrating that the systematic application of the evidence-based seven-step implantation strategy increases the success rate, minimizes early and late complications, which result in increased patient safety.

QI-452785-4 DURING CARDIAC ELECTROPHYSIOLOGY PROCEDURES ULTRASOUND GUIDANCE OF VENOUS PUNCTURE REDUCES MAJOR AND TOTAL VASCULAR COMPLICATIONS - A META-ANALYSIS

Puncture site vascular complications (VCs) are the most common complications of invasive electrophysiology (EP) procedures. The use of vascular ultrasound during puncture is already included in the guidelines of other medical fields, e.g. intensive care, and also widely used in EP labs around the world, but not yet standard practice in all of them. Our aim was to conduct a meta-analysis which compares anatomical guidance to the use of ultrasound during the femoral venous puncture in conjunction with electrophysiology procedures. In contrast to the previous meta-analyses, we aimed to use a uniform endpoint and to involve new publications to improve patients numbers. In order to find articles which report, both with and without ultrasound guidance, the rate of vascular complications during EP procedures, a systematic search was performed in the relevant electronic databases. Major VCs (MVCs), as defined in the 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus) were the primary endpoint. AV-fistula, pseudoanerurysm and major bleeding (each separately), minor VCs, total VCs and inadvertent arterial punctures were defined as secondary endpoints, For statistical analysis we used a random effects model with the Mantel-Haenszel method. Data on 23605 patients was reported by the 14 articles matching our selection criteria. The primary outcome was reported on 13050 of them (in 10 articles), with 200 (156 %) reaching the primary endpoint of an MVC. The occurrence of MVCs was significantly reduced by the routine use of ultrasound during the puncture (29/4542 vs. 171/8508, OR 0.22 [0.10-0.50], p<0.001). Moreover, the incidence of several secondary endpoints was also significantly lower: total vascular complications – OR 0.27 [0.13-0.53] (p<0.001), minor vascular complications: OR 0.25 [0.16-0.74], accidental artery puncture – OR was 0.20 [0.09-0.41] (p<0.001). There was insufficient data reported regarding AV-fistula, pseudoanerurysm and major bleeding specifically. While using a more uniform MVC definition compared to previous meta-analyses and covering more than 1.5 times as many patients, we demonstrated that ultrasound guidance for femoral venous puncture during EP procedures is significantly beneficial. Above all, the rate of MVCs and total VCs is reduced by this technique. These results show that its routine use should be considered in every EP lab and this could bring important improvements in patient safety.

Major vascular complications are reduced by ultrasound guided venous puncture compared to conventional technique in cardiac catheter ablation: a meta-analysis

Abstract Background Puncture site vascular complications are relatively common during invasive electrophysiology. One of the most promising measures to minimize these adverse events is the use of vascular ultrasound during puncture. Objective We aimed to carry out a meta-analysis comparing conventional, anatomically guided femoral venous puncture to ultrasound-guided puncture during electrophysiology procedures, which, in contrast to, the previous meta-analyses, used a uniform endpoint and involved novel trials resulting in higher patients numbers. Methods We conducted a systematic search in relevant electronic databases for articles reporting the rate of vascular complications during EP procedures both with and without ultrasound guidance. We defined major vascular complications (MVCs, as defined in the 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus) as the primary endpoint. Secondary endpoints were arteriovenous fistula, pseudoanerurysm and major bleeding separately, and minor vascular complications and accidental arterial punctures. Statistical analysis was performed using a random effect model with the Mantel-Haenszel method. Results A total of 23605 patients were included in the 14 articles matching our selection criteria, and there were data on the primary outcome in 15160 of them (in 11 articles), with 236 (1.6%), who reached the primary endpoint of an MVC. Routine application of ultrasound guidance significantly reduced the incidence of major vascular complications (42/5645 vs. 194/9515, OR 0.36 [0.23–0.55], p&amp;lt;0.001). Furthermore, we found significantly lower incidence in several of our secondary endpoints: for total vascular complications the OR was 0.27 [0.13–0.53] (p&amp;lt;0.001), for major bleedings the OR was 0.42 [0.24–0.74] and for inadvertent artery puncture the OR was 0.24 [0.15–0.38] (p&amp;lt;0.001). Data was insufficiently reported in respect of arteriovenous fistulae and of pseudoanerurysms specifically. Conclusion With more than double of the number of patients compared to the previous meta-analyses, and with a more consistent MVC definition, we showed that ultrasound guidance for femoral venous puncture has significant benefits, most importantly reduces the incidence of major vascular complications and total vascular complications. Our results underscore the need for a randomized controlled trial in the question, with potentially important implications for daily clinical practice and patient safety. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1–2016-0017 (“National Heart Program”) has been implemented with the support provided by the Ministry of Innovation and Technology of Hungary from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. -Project no. MEC_R-141548 has been implemented with the support provided by the Ministry of Innovation and Technology of Hungary from the National Research, Development and Innovation Fund, financed under the MEC_R_21 funding scheme.

Iatrogenic catheterisation of subclavian artery while cannulating internal jugular vein.

Sir, Placement of a central venous catheter (CVC) carries a complication rate of 17.9%.[1] Use of ultrasound guidance has been advocated as standard of care to reduce complications and achieve higher success rate.[234] However, ultrasound-guided cannulation does not altogether negate accidental arterial puncture as has been found in our patient. A 3-year-old female child weighing 16.9 kg and having a midline brain stem tumour with hydrocephalus was posted for elective tumour excision. Following uneventful tracheal intubation and maintenance of anaesthesia with 50% oxygen in air, 1.5% sevoflurane and remifentanil (0.25 μg/kg/min) infusion, it was decided to place an arterial line and a CVC. Positive end expiratory pressure of 4-cmH2O was now momentarily applied, which resulted in a well-dilated right internal jugular vein (IJV) on imaging using linear probe of Mindray ultrasound machine (Shenzhen Mindray Bio-medical Electronics co. Ltd., Zhenzhen 518057, P.R. China). Right IJV was punctured at first attempt by a 4th-year anaesthesia resident with the needle directed at a 45° angulation. After free aspiration of blood, a guide wire was passed through the needle uneventfully. Following dilatation of the cannulation site, a 5.5 Fr paediatric multi-lumen CVC with blue flex tip (Arrow International, Inc, 2400 Bernville Road, PA, USA) was passed. All three ports were checked for free aspiration of blood. The CVC was fixed at 8 cm mark and sterile transparent dressing was applied. At this stage, an intravenous line containing 5% dextrose in 0.45% normal saline was attached to the distal 20-gauge catheter port. Contrary to expectation, there was no flow of the fluid although blood could be freely aspirated from this port. However, a minimal spontaneous backflow of blood was noted in the infusion line. Despite changing to a different port, the infusion was not dripping. At this stage, doubt was raised that the line could be in an artery, and the transducer of the arterial line was connected to the CVC and an arterial waveform was noted. Before removing the catheter, ultrasound imaging was done to confirm the position of the catheter in the artery. As expected, the puncture site and IJV were significantly to the right of the carotid artery. Further scanning and change of probe angle revealed a pulsating vessel underneath the jugular vein, which could be the subclavian artery (SA). Surprisingly, the catheter was seen to pass through the internal jugular lumen and then to lie in the SA [Figure 1]. The CVC was now removed and compression for 5 min was applied. A fresh CVC was placed in the same IJV uneventfully.Figure 1: Internal jugular vein and the subclavian artery with evidence of central venous catheter passing through them. (IJV-Internal jugular vein, SCA-Subclavian artery, CVC-Central venous catheter)We postulate a sequence of events that led to inadvertent SA puncture in our patient. The SA was about 2.5 mm deeper to the IJV as revealed by ultrasound [Figure 1]. The indentation of the wall of IJV while puncturing the vein or displacement of needle tip later after the probe was removed could be the reason for the needle tip entering the SA. We suggest five key points to avoid this mistake while cannulating IJV in paediatric patients where the SA is only a few mm away. First, needle should be kept angulated in relation to skin, close to 30° instead of 45° during puncture as this tangential approach results in less application of posterior forces that tend to collapse the vein wall. Also, angulation helps where the IJV diameter is less than the longitudinal length of bevel of needle.[5] Second, double wall puncture should be kept in mind where the vein diameter is small.[5] Third, it is essential that the tip of the needle be constantly identified with ultrasound as it approaches the vein and puncture is made.[6] Fourth, the path of guide wire should be confirmed by ultrasound prior to dilatation of the vessel. Lastly, a higher neck approach may be adopted in children so as to increase the distance between IJV and the SA, thereby reducing the possibility of its inadvertent puncture. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Vascular access unit: Six-years experience report in France.

The role of nurses in peripherally inserted central catheters (PICC) placement has been limited in France. Having a fully trained nurse-led PICC team can positively impact nursing profession and make better use of valuable human and economic healthcare resources. It can also improve the standards of patient's care, procedural experience, and safety. The aim of this article is to report the successful outcomes of nurse-led PICC team performed over a 6-year period from a single central hospital in France. The authors reviewed all PICCs insertions performed by their trained nurse led team between 2014 and 2019. All quantitative and qualitative variables were considered: the patients admitted, the type of PICC inserted, overall procedural time, the mentor's help, the insert failures, the number of punctures required, the procedural pain utilizing Visual Analog Scale (VAS), any procedural complications, chest X-rays needed, the follow up to the eighth day (D8). From 2014 to 2019, 12,687 PICC were inserted with 128 failed procedures (1%). In 2019, 73% of procedural insertion time was less than 10 min. The request of support rapidly decreased to 2 calls/month. More than 90% of procedures were associated with mild pain (VAS ⩽ 3). After the first month of training, 81% of all procedures were performed with a single insertion puncture. Accidental artery puncture during procedure was 0.5%. The authors found room for improvement, progressing from 97% in the first year to 99% in 2019. Furthermore, the authors found that only 1.85% of all catheters developed local infection within D8, and only 0.83% evolved in vein thrombosis. Total bloodstream infection was at 0.1%. The authors report successful outcomes from data collected during the 6-year period demonstrating clear benefits of a nurse-led vascular access team with regard to system wide efficiencies and patient satisfaction.

CAROTID ARTERY PSEUDOANEURYSM FOLLOWING DIALYSIS LINE INSERTION- FATAL BUT AN AVOIDABLE COMPLICATION – a case report

ABSTRACT BACKGROUND: Carotid artery pseudoaneurysm due to accidental arterial puncture during internal jugular vein line insertion is a fatal as well as an avoidable complication if done in a proper way . CASE PRESENTATION: We report a case of right carotid artery pseudoaneurysm following right internal jugular vein cannulation . A 43-year gentleman, chronic kidney disease stage 5, on maintenance hemodialysis, developed a pulsatile swelling of the neck six days after a Central venous catheter placement in the right internal jugular vein, which was later diagnosed to be a pseudoaneurysm of the right common carotid artery. Surgical repair of the pseudoaneurysm was done . CONCLUSIONS Arterial complications are unavoidable however good the technique of central line insertion might be . However , a correct technique along with ultrasound guidance may reduce the incidence of arterial injury and its fatal complications during central line placement .

High Deep Femoral Artery Bifurcation Can Disturb Safe Femoral Venous Access: CT Assessment in Patients Who Underwent Femoral Venous Access Under Doppler Ultrasound Guidance.

Purpose: To retrospectively evaluate the variations of deep femoral artery (DFA) bifurcation on computed tomography (CT) and technical success in femoral venous access. Materials and Methods: CT images of 353 patients who underwent adrenal venous sampling were evaluated. Height with relation to the inferior border of the femoral head and direction of DFA bifurcations were classified as follows: type L, low bifurcation; type H1, high lateral bifurcation; type H2, high posterior to posterolateral bifurcation; type H3, high posteromedial bifurcation; and type H4, high medial bifurcation crossing in front of the femoral vein. Technical success and complications during femoral venous access were also evaluated. Results: The frequencies of types L, H1, H2, H3, and H4 were 82.7%, 9.1%, 6.9%, 0.4%, and 0.9%, respectively. In 92.2% of type H1 and 69.4% of type H2, the superior femoral artery displaced medially by the high DFA partially overlapped the femoral vein. Upon the inclusions of H3 and H4, in 14.4% of cases, the high DFAs could obstruct the access route to the femoral vein. Using Doppler ultrasound guidance, no significant differences were observed in the rates of success for puncture in the first attempt (84.5% vs. 75.4%, p = 0.122) and accidental arterial puncture (1.0% vs. 0%, p = 1.00) between low and high DFA bifurcations, respectively. Conclusions: High DFA bifurcation is observed in 17.3% of patients and could obstruct the access route to the femoral vein. This can be evaluated using Doppler ultrasound guidance to avoid accidental arterial puncture during femoral venous access.

Risk factors for inadvertent arterial puncture during subclavian vein catheterization.

Central vein catheterizations facilitate the establishment of reliable venous pathways in emergent medical situations. The subclavian is an important vein for central venous catheterizations. But, inadvertent arterial punctures during subclavian vein catheterizations are more dangerous than those during jugular or femoral vein catheterizations, because of the lack of a reliable compression site. We aimed to identify risk factors for the occurrence of inadvertent arterial puncture during subclavian vein catheterizations in crowded emergency rooms. We evaluated 190 patients undergoing bedside subclavian vein catheterizations in our emergency room, from which 62 patients experienced inadvertent arterial punctures. We evaluated possible risk factors from basic physical or laboratory tests that can easily be obtained in the ER, and performed Chi-square test, Kruskal-Wallis ANOVA, non-conditional logistic regression analysis, and receiver-operating characteristic curves to determine the cut-off values of the identified risk factors. We identified age, BMI, and serum pre-albumin level as significant risk factors for inadvertent arterial puncture during subclavian vein catheterization (p<0.05) through regression analyses (odds ratios of 1.043, 0.719 and 0.989; and receiver-operating characteristic curves with AUCs of 0.741, 0.818, and 0.717, respectively). The cut-off values for age, BMI and serum pre-albumin level were 66.5 years old, 21.12 and 109.5 mg/L, respectively. We found that patients with poor nutritional status (BMI <21.12 and serum pre-albumin <109.5 mg/L) or older than 69.5 years tended to experience more accidental arterial punctures during subclavian vein catheterizations, probably due to atrophy or diminished peri-vascular support tissues in patients with poor nutritional statuses that make it difficult to obtain adequate chest extensions.

Iatrogenous puncture of the aortic arch closed with ProGlide.

An 89-year-old woman was referred to our hospital owing to syncope caused by an atrioventricular conduction disease. She presented with a past medical history of hypertension, dyslipidemia, and depression. A temporary balloon-tipped pacemaker electrode was inserted in the emergency department through the right jugular vein. Jugular catheter placement is a routine procedure. Several authors recommend the use of ultrasound guidance to avoid complications, such as arterial injury. Saugle et al1Saugle B. Scheeren T.W.L. Teboul J.L. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice.Crit Care. 2017; 21: 225Crossref PubMed Scopus (135) Google Scholar reviewed the literature and described six steps to perform ultrasound-guided jugular catheter placement: identify the anatomy of the insertion site and localize the vessels, confirm the patency of the jugular vein with a compression test, use real-time ultrasound guidance for puncture of the vein, confirm needle position in the vein, confirm the wire position, and confirm the catheter position in the vein. In our case, a percutaneous echocardiography-guided puncture of the jugular vein was made; however, once the 6F sheath was placed inside, an arterial flow was obtained from the sheath; therefore, the on-call cardiologist considered it to be placed in the carotid artery. Upon examination, an abnormally oblique position of the sheath was observed in the patient's neck (A). Doppler ultrasound examination revealed no contact between the sheath and the supra-aortic trunks. Arteriography was performed through the sheath, revealing an introducer placed in the aortic arch (B and C/Cover). After a multidisciplinary consensus, owing to the patient's age and the difficulty of open sheath withdrawal, a percutaneous artery closure device was used. Under general anesthesia and controlled hypotension, the 6F sheath was removed and the aortic arch was closed with a ProGlide (Abbott Laboratories, Chicago, Ill). A computed tomography scan after the procedure revealed a hematoma at the superior mediastinum close to supra-aortic trunks without signs of bleeding (D). The patient was admitted to the coronary unit with strict control of the blood pressure. After 48 hours, a permanent pacemaker was inserted. One week later, the patient was discharged home. The patient provided consent for the publication of her case details and imaging. Inadvertent arterial puncture during central venous catheter placement is a well-known complication.2Bowdle A. Vascular complications of central venous catheter placement: evidence-based methods for prevention and treatment.J Cardiothorac Vasc Anesth. 2014; 28: 358-368Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar In the majority of cases of misplaced jugular catheters, the carotid artery is punctured. Accidental aortic arch puncture is a rare complication and its treatment includes open surgery with median sternotomy.3Sellem M.I. Al-Hashemy A.A. Al-Naemi A. Ectopic intra-aortic insertion of a subclavian central venous catheter: case report and review of the literature.J Thorac Cardiovasc Surg. 2004; 127: 1515-1516Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Since the advent of percutaneous closures, some authors have described their use in the management of accidental artery puncture.4Pikwer A. Acosta S. Kölbel T. Malina M. Sonesson B. Akeson J. Management of inadvertent arterial catheterisation associated with central venous access procedures.Eur J Vasc Endovasc Surg. 2009; 38: 707-714Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar We found one case in the literature where an aortic arch puncture was treated with a percutaneous closure. In this case, the puncture of the aorta was done during subclavian catheter placement and they used Angio-Seal Vascular Closure Device (St Jude Medical, Saint Paul, Minn).5Leijdekkers V.J. Go H.L.S. Legemate D.A. Reekers J.A. The use of percutaneous closure device for closure of an accidental puncture of the aortic arch; a simple solution for a difficult problem.Eur J Vasc Endovasc Surg. 2006; 32: 94-96Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In our case, there was no option for open repair owing to patients comorbidities. We preferred to use a suture-mediated closure system (ProGlide) because we have experience using this system in peripheral arteries. This case highlights that complications may occur and, even though there is no indication for the use of the ProGlide system in aortic puncture, we have to be able to individualize the treatment plan for this patients without other available options. The authors thank Dr Bernat Lloret Villas for his expertise and assistance with patient management.

Centrally inserted central catheters in preterm neonates with weight below 1500 g by ultrasound-guided access to the brachio-cephalic vein.

Central venous access in critically ill newborns can be challenging. Ultrasound-guided brachio-cephalic vein catheterization is a relatively new procedure, recently introduced in several neonatal intensive care units. The aim of this study is to evaluate the safety and feasibility of such a technique in preterm babies. Retrospective analysis of prospectively collected data on ultrasound-guided central venous catheter insertion in preterm neonates. Neonatal intensive care unit. Critically ill preterm neonates with weight below 1500 g requiring a central access. Ultrasound-guided brachio-cephalic vein catheterization. Thirty centrally inserted catheters were placed in 30 neonates. The success rate of the procedure was 100%. No case of accidental arterial or pleural puncture was registered during the study period. The brachio-cephalic vein can be safely catheterized in preterm newborns requiring intensive care after appropriate training.

Off-label use of Proglide percutaneous closure device in iatrogenic arterial catheterizations: Our experience.

Incidental arterial puncture is one of the main complications associated with central venous catheter placement. Manual compression to achieve hemostasis in subclavian and carotid artery punctures is often ineffective because of the anatomical arterial position. Accidental cannulation has traditionally been treated with open surgery or endovascular treatment, but such procedures are not exempt from complications. Report our experience with ultrasound-guided off-label use of Perclose ProGlide (Abbott Vascular Inc., Santa Clara, CA, USA) in patients with iatrogenic arterial cannulation. Six unstable patients with accidental arterial catheterization during placement of a central venous catheter: five of them in the subclavian artery and one in the right common carotid artery. Ultrasound-guided percutaneous closure was performed at bedside using a Perclose ProGlide (Abbott Vascular Inc., Santa Clara, CA, USA). All patients underwent duplex ultrasound 6, 12, 24, and 48 h postprocedure, and no complications associated with percutaneous closure (embolism, ischemia, stenosis, or arterial occlusion, bleeding, pseudoaneurysm, etc.) were described. Accidental artery puncture during central venous catheterization is an uncommon situation but can be effectively managed by using percutaneous vascular closure device. It is a reliable alternative that should be considered as a first-line approach before endovascular or open surgery, specially in patients with unstable conditions in which it is possible to be performed without transfer to an operation room.

Accidental arterial catheterisation during a maxillary nerve block using a modified infraorbital approach in a dog

The maxillary nerve block (MNB) is a local anaesthetic technique used in dentistry and oromaxillofacial surgery, with recent popular use for minimising adverse reactions during rhinoscopy. A modified approach via...

Short-axis versus long-axis approach in ultrasound-guided central venous cannulation: an updated systematic review and meta-analysis

To compare the success rate and safety of the short-axis (SAX) approach and long- axis (LAX) approach to ultrasound-guided central venous cannulation. Electronic bibliographic databases including PubMed, Cochrane Library, Science Direct, and Web of Science were searched for randomized controlled trials comparing ultrasound-guided central venous cannulation via the LAX and SAX approaches published during the period from January, 2011 to October, 2017. We extracted the data from the eligible studies and assessed the first-attempt success rate, overall puncture success rate and complication rate of the two approaches. The relative risk (RR) with the 95% CI was calculated using a fixed or random effects model. Seven randomized controlled trials were included for meta-analysis. The results showed that the first-attempt success rate was significantly higher in the SAX group than in the LAX group (RR=1.27, 95%CI: 1.11-1.46; P=0.0005, I2=49%), but the overall puncture success rate did not differ significantly between the two approaches (RR=1.04, 95%CI: 0.97-1.10; P=0.27, I2=84%). The incidence of accidental arterial puncture with the SAX approach was significantly lower than that with the LAX approach (RR=1.04; 95%CI: 1.01-1.08; P=0.01, I2=30%). Ultrasound-guided central venous cannulation via the SAX approach, as compared with the LAX approach, can increase first-attempt success rate and reduce the incidence of accidental arterial puncture.

Assessment of head and neck position for optimal ultrasonographic visualisation of the internal jugular vein and its relation to the common carotid artery: A prospective observational study.

Background and Aims:There is a wide variation in the anatomical relationship of the Internal Jugular Vein (IJV) to the Common Carotid Artery (CCA). This makes landmark based techniques of IJV cannulation and head rotation questionable and may lead to accidental arterial puncture. We conducted this study to determine the anatomical relation of the IJV to the CCA using (USG) in patients undergoing IJV cannulation for central venous access, and to analyse the effect of head rotation on this relationship.Material and Methods:A prospective observational study was conducted on 100 patients requiring central venous access, in the operation theatre or the intensive care unit. Anatomical relationship of the IJV to CCA at the level of the cricoid cartilage was analysed by noting the segment position (1-12) around the CCA using a high frequency linear USG probe on patients in neutral head position, on both sides and also with the head rotated to the contra lateral side by 15° and 45°.Results:Antero-lateral segments 1 and 2 were the most common positions (50% on the right and 73% on the left side). Change in segment causing increase in overlap of IJV and CCA with 15° head rotation was seen in 44% subjects on the right and 39% on the left. Statistically, a higher number of subjects showed overlap with 45° rotation (99% on right and 97% on left, P < 0.05).Conclusion:There is a wide variation in anatomical location of the IJV in relation to the CCA as seen by USG. Excessive head rotation causes overlap of IJV over CCA which may cause inadvertent arterial puncture, even under USG guidance. Thus, it is preferable to cannulate the IJV in neutral or near neutral head and neck position.

Prospective observational study on the complications and tolerability of a peripherally inserted central catheter (PICC) in neuro-oncological patients.

The use of central venous catheters with peripheral insertion (PICC) has increased rapidly in recent years, particularly in cancer patients. The benefits provided may occasionally be affected by relevant complications, such as infections and thrombotic events, especially in neuro-oncological patients. To date, the risk of PICC-related complications in this subset of patients is unknown, as is tolerability. As a primary objective, this study aimed to collect complications related to PICCs in primary neuro-oncological patients. As a secondary objective, the study aimed to evaluate PICC tolerability. Neuro-oncological patients with PICCs that were placed as part of normal clinical practice at IRCCS Neurologico C. Besta were consecutively enrolled in the study. PICC-related complications were recorded immediately (during the procedure), early (within 1week after PICC insertion), and late (1-3-5months after PICC placement). At the same time points, all patients were also evaluated for tolerability through interviews with semi-structured, open-ended questions. Sixty patients were enrolled (41 males and 19 females, with a median age of 56.2years). Excluding loss to follow-up, 33/49 patients developed at least one complication related to the PICC. Immediate complications mainly included hematoma (8), accidental arterial puncture (4), and primary malpositioning (3). Regarding early and late complications, 3 device-related infections, 8 thrombotic events, and 20 mechanical complications were registered. Semi-structured interviews revealed an overall positive experience with the device. The most negative impact was on hygiene habits, with 34 patients becoming caregiver-dependent. Over time, almost all patients became used to the device and perceived greater security during chemotherapy. A strongly negative issue was the difficulty of relying on competently trained healthcare personnel in outpatient setting. The results showed a nonnegligible increased thromboembolic risk in neuro-oncological patients with PICCs, almost double that in historical oncological populations. It is essential to extend the study to a greater number of patients to achieve reliable results and to identify patients at high risk. The device seems to be positively accepted by the majority of patients, without affecting activities of daily living.

A modified approach for ultrasound-guided axillary venipuncture in the infraclavicular area: A retrospective observational study.

Catheterization of the axillary vein in the infraclavicular area has important advantages in patients with long-term, indwelling central venous catheters. The two most commonly used ultrasound-guided approaches for catheterization of the axillary vein include the long-axis/in-plane approach and the short-axis/out-of-plane approach, but there are certain drawbacks to both approaches. We have modified a new approach for axillary vein catheterization: the oblique-axis/in-plane approach. This observational study retrospectively collected data from patients who underwent ultrasound-guided placement of an axillary vein infusion port in the infraclavicular area at the Central Venous Access Clinics of Zhongshan Hospital at Fudan University between March 2014 and May 2017. The patients' demographic data, success rate of catheterization, venous catheterization site, and immediate complications associated with catheterization were recorded. Between March 2014 and May 2017, a total of 858 patients underwent placement of an axillary vein infusion port in the infraclavicular area at our center. The ultrasound-guided oblique-axis/in-plane approach was used for all patients, and the venipuncture success rate was 100%. Two cases of accidental arterial puncture and one case of local hematoma formation were reported, and no other complications, such as pneumothorax or nerve damage, were reported. The ultrasound-guided oblique-axis/in-plane approach is a safe and reliable alternative to the routine ultrasound-guided approach for axillary venous catheterization.

An Accidental Arterial Puncture and Anticoagulation after Internal Jugular Vein Catheterization Resulting in Massive Hematoma and Airway Compromise

An Accidental Arterial Puncture and Anticoagulation after Internal Jugular Vein Catheterization Resulting in Massive Hematoma and Airway Compromise

Frequency of in-hospital adverse outcomes and cost utilization associated with cardiac resynchronization therapy defibrillator implantation in the United States.

The utilization of cardiac resynchronization therapy defibrillator (CRT-D) has increased significantly, since its initial approval for use in selected patients with heart failure. Limited dataexist as for current trends in implant-related in-hospital complications and cost utilization. The aim of our study was to examine in-hospital complication rates associated with CRT-D and their trends over the last decade. Using the Nationwide Inpatient Sample, we estimated 378 248 CRT-D procedures from 2003 to 2012. We investigated common complications, including mechanical, cardiovascular, pericardial complications (hemopericardium, cardiac tamponade, or pericardiocentesis), pneumothorax, stroke, vascular complications (consisting of hemorrhage/hematoma, incidents requiring surgical repair, and accidental arterial puncture), and in-hospital deaths described with CRT-D, defining them by the validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code. Mechanical complications (5.9%) were the commonest, followed by cardiovascular (3.6%), respiratory failure (2.4%), and pneumothorax (1.5%). Age (≥65 years), female gender (OR, 95% CI; P value) (1.08, 1.03-1.13; 0.001), and the Charlson score ≥3 (1.52, 1.45-1.60; <0.001) were significantly associated with increased mortality/complications. The overall complication rate in patients undergoing CRT-D has been increasing in the last decade. Age (≥65), female sex, and the Charlson score ≥3 were associated with higher complications. In patients who underwent CRT-D implantation, postoperative complications were associated with significant increases in cost.