Accidental Puncture Research Articles

Ultrasound-guided vascular catheterization in critically ill patients with nonpulsatile continuous circulation veno-arterial extracorporeal membrane oxygenation or ventricular assist device support

Background Vascular access can be challenging in patients with obesity, impalpable pulsations, hemodynamic instability, thrombocytopenia, and coagulopathy. Our aim was to study the clinical effectiveness of vascular ultrasound (US) in arterial and venous catheterizations in critically ill patients with nonpulsatile circulation admitted at cardiac critical care units and to compare with the landmark techniques. Patients and methods This retrospective study included adult patients from January 2015 to January 2019 who had been admitted to the adult cardiac critical care unit with left ventricular assist device or veno-arterial extracorporeal membrane oxygenation and required vascular access. Results In 152 critically ill patients, 292 vascular catheters were inserted. The first-attempt success was achieved in 77.9 versus 34.6% (P=0.001) and the whole procedural success was 100 versus 67.5% (P=0.001) in the US and landmark groups, respectively. The number of attempts was 1.7±0.6 versus 1.2±0.4 (P=0.001) and the complications occurred in 2.5 versus 21.2% (P=0.001) in the US and landmark groups, respectively. Jugular catheterization was done in 42.9 versus 19.3% (P=0.001), while subclavian cannulation was done in 5 versus 42.3% (P=0.001) in the US and landmark groups, respectively. Iatrogenic pneumothorax happened in 0 versus 3.1% (P=0.001), accidental puncture of the adjacent artery happened in 0 versus 14.7% (P=0.001), and hematoma formation happened in 2.5 versus 9% (P=0.03) in the US and landmark groups, respectively. Conclusion Arterial and venous catheterizations guided by US in critically ill patients with nonpulsatile circulation and unstable hemodynamics were associated with higher success and more safety compared with the landmark techniques.

Echocardiographic diagnosis of permanent pacemaker lead malposition in the left ventricle: A case study.

Inadvertent endocardial lead malposition is recognized as a rare incident which is usually underreported and if recognized during implantation can be easily corrected. This phenomenon is caused by the ventricular lead unintentionally crossing a pre-existing patent foremen ovale, septal defects (atrial or ventricular) or directly from the aorta via an accidental subclavian puncture resulting in the lead implanting into the left ventricle. While this is a rare occurrence we report, the incidental finding of pacemaker lead malposition during a routine follow-up transthoracic echocardiogram and the benefits of three-dimensional transesophageal echocardiography in this patient prior to lead extraction.

Magnetic needle-tracking device for ultrasound guidance of radial artery puncture: A randomized study on a simulation model.

Ultrasound-guidance of radial artery catheter insertion improves the first attempt success and reduces the occurrence of hematomas. Needle-tracking devices optimize needle-ultrasound beam alignment by displaying in real-time the needle tip position. We compared the median time need by experienced physicians to achieve radial artery puncture using either a conventional ultrasonography device (CUD) or a magnetic needle-tracking ultrasound device (MUD) in a simulation training arm model. Fifty experienced residents and physicians performed two punctures in randomized order with the CUD and the MUD. The primary outcome was puncture duration; the secondary outcomes were puncture success, rate of accidental vein puncture, and practitioner's comfort (subjective scale 0-10). The median [lower-upper quartile] puncture time was 10 [6-14] seconds when using CUD and 4 [3-7] seconds when using MUD (P < .01). In the multivariate analysis, MUD use was associated with decreased puncture duration whatever the puncture order (OR 1.13 [1.07-1.20], P < .01). The participants performed 99 (99%) successful punctures: 50 with the MUD (100%) and 49 with the CUD (98%). There was no accidental venous puncture. The practitioner's comfort level was 6.5 [6, 7] with the CUD and 8 [7-9] with the MUD (P < .01). MUD reduced radial artery puncture time and improved physician comfort in a simulation training arm model.

Conversion rate of laparoscopic or robotic to open sacrocolpopexy: are there associated factors and complications?

To evaluate the conversion rate of laparoscopic or robotic to open sacrocolpopexy and to identify associated factors in a large population-based database. We used Health Care Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) databases 2005-2014. We extracted data on apical suspension and synthetic mesh with laparoscopy or robot in adult women using International Classification of Diseases, ninth edition, Clinical Modification (ICD-9-CM) codes. We evaluated the rate of conversion and used logistic regression to study the association with risk factors. We identified 3295 women with laparoscopic or robotic sacrocolpopexies. There were 2777 robotic procedures with 37 conversion (1.33%) and 518 laparoscopic procedures with 37 conversions (7.14%), with an overall conversion rate of 2.2%. Median age was 62years [interquartile range (IQR) = 55-69]. Concomitant hysterectomy was significantly more frequent in the robotic than laparascopic group (41.7% versus 13.9%, p < 0.01) and was not associated with conversion. Factors associated with lower conversion included a robotic approach (adjusted odd ratio (aOR) 0.32 [95% CI 0.19-0.54]) and private insurance (aOR 0.53 [95% CI 0.32-0.86]). Factors associated with higher conversion were obesity (aOR 3.27 [95% CI 1.72-6.19]) and lysis of adhesions (aOR 3.32 [95% CI 1.89-5.85]). Accidental organ puncture was significantly associated with conversion (14.9% versus 3.8%; p < 0.01). In this American database, the rate of conversion of laparoscopic or robotic to open sacrocolpopexy was low. The majority (84%) of minimally invasive sacrocolpopexies used a robotic approach, which was associated with a lower risk of conversion. Obesity and lysis of adhesions were associated with a higher risk of conversion.

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.

Accidental Puncture of a Dialysis Catheter into the Brachiocephalic Trunk.

A 22-year-old male with underlying end-stage renal failure was referred to our center for a malpositioned dialysis catheter. Imaging showed the tip of the catheter to be placed in the brachiocephalic trunk; the patient was, however, asymptomatic. Surgical removal of the malpositioned catheter followed, with no postoperative complications.

Seroprevalence of the hepatitis C virus in healthcare personnel of the IMSS.

Healthcare workers (HCWs) are considered an at-risk population for hepatitis C virus (HCV) transmission. Seroprevalence of HCV in Mexico is 1.4% and is similar in HCWs at 0.5-2%. To determine the seroprevalence of HCV in HCWs at the Hospital de Especialidades Centro Médico Nacional La Raza (HECMNR) and correlate the positive cases with the viral load. An observational, longitudinal, descriptive study was conducted on HCWs at the HECMNR that voluntarily answered a risk factor questionnaire and gave a capillary blood sample for detecting antibodies to HCV. Anti-HCV antibody detection was performed through the rapid colloidal gold-enhanced immunochromatographic assay for the qualitative identification of antibodies to HCV. When positive, quantitative HCV RNA PCR testing was carried out. A total of 391 rapid anti-HCV tests were performed and the mean participant age was 32 years. A total of 214 (54.73%) of the HCWs belonged to clinical services, 120 (30.69%) to surgical services, and 57 (14.57%) to the nursing service; 254 (64.96%) participants were medical residents and 137 (35%) were staff personnel. The most prevalent risk factors were accidental puncture wounds (n = 261, 66.75%) and dental procedures (n = 229, 58.56%). Four samples (1.02%) were positive for anti-HCV antibodies and the HCV RNA PCR test was not positive in any of the samples. HCWs did not have a greater seroprevalence for HCV, compared with the general population, and no cases of viremia were reported.

Concordance between the loss of resistance technique and ultrasound in measuring the distance from the skin to the epidural space in pediatric patients: Observational study

Introduction: The use of ultrasound in regional anesthesia has become a standard technique to improve nerve block accuracy and reduce associated complications. The literature reports a good correlation between the distance from the skin to the dura mater or the ligamentum flavum measured on ultrasound and the conventional technique of “loss of resistance”. Latin American populations have not been included in the studies conducted so far but, because of differences in physical build, it is important to determine whether this correlation is maintained in the various populations. This paper offers new information about the role of ultrasound in determining the distance to the ligamentum flavum and recognizing the proximity of the dura mater to avoid accidental puncture of this structure in Latin American populations.&#x0D; Objective: To determine correlation and concordance in estimating the distance from the skin to the epidural space between the loss of resistance technique and ultrasound measurement.&#x0D; Methodology: Observational study conducted in 52 pediatric patients who received general anesthesia plus peridural analgesia for acute perioperative pain management between July 2014 and November 2015 to assess correlation and concordance between loss of resistance and ultrasound measurement of distance to the epidural space.&#x0D; Results: There is a correlation between distances measured using the two techniques, which appears to be higher as patient age increases. As for concordance, the study found that 0.43 cm should be added to the ultrasound measurement to achieve agreement with the distance obtained using the loss of resistance technique; however, the interval between the two measurements is 1.15 cm.&#x0D; Conclusions: A correlation was found between the measurement taken from the skin to the peridural space using ultrasound and the measurement obtained with the traditional needle puncture and loss of resistance technique. Although concordance was not as expected and the distance measured with ultrasound may be smaller than the real measurement with the needle, ultrasound offers good guidance regarding proximity to the peridural space.

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.

Ultrasound-guided Axillary Vein Puncture in Cardiac Lead Implantation: Time to Move to a New Standard Access?

Cardiac stimulation therapy has evolved significantly over the past 30 years. Currently, cardiac implantable electronic devices (CIED) are the mainstream therapy for many potentially lethal heart conditions, such as advanced atrioventricular block or sustained ventricular tachycardia or fibrillation. Despite sometimes being lifesaving, the implant is surgical and therefore carries all the inevitable intrinsic risks. In the process of technology evolution, one of the most important factors is to make it safer for the patient. In the context of CIED implants, complications include accidental puncture of intrathoracic structures. Alternative strategies to intrathoracic subclavian vein puncture include cephalic vein dissection or axillary vein puncture, which can be guided by fluoroscopy, venography or, more recently, ultrasound. In this article, the authors analyse the state of the art of ultrasound-guided axillary vein puncture using evidence from landmark studies in this field.

Dual-wavelength fiber-optic technique to assist needle cricothyroidotomy

The traditional needle cricothyroidotomy procedure is performed blindly without any medical equipment. Complications including posterior tracheal wall perforation, accidental vessel puncture, and missed tracheal puncture are reported. Therefore, we proposed a dual-wavelength fiber-optic technique based on the technique of near-infrared spectroscopy to assist operators performing needle cricothyroidotomy in a swine model. We embedded optical fibers in a 16-gauge intravenous needle catheter. Real-time data were displayed on an oscilloscope, and we used the program to analyze the data immediately. The change of optical density corresponding to 690-nm and 850-nm wavelengths and hemoglobin parameters (HbO2 and Hb concentrations) was analyzed immediately using the program in the laptop. Unique and significant optical differences were presented in this experiment. We could easily identify every different tissue by the change of optical density corresponding to 690-nm and 850-nm wavelengths and hemoglobin parameters (HbO2 and Hb concentrations). Statistical method (Kruskal-Wallis H test) was used to compare differences in tissues at each time-point, respectively. The p values in every tissue in optical density change corresponding to 690 nm and 850 nm were all < 0.001. Furthermore, the p values in every tissue in Hb and HbO2 were also all < 0.001. The results were statistically significant. This is the first and novel study to introduce a dual-wavelength embedded fibers into a standard cricothyroidotomy needle. This proposed system might be helpful to provide us real-time information of the advanced needle tip to decrease possible complications.

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.

SAT-672 An Unusual and Enigmatic Etiology for Diabetic Ketoacidosis: Safety Needles

Diabetic ketoacidosis is associated with a mortality rate of upto 6.1% and accounts for an estimated 115000 hospital discharges per year in the United States. In order to reduce mortality related to DKA, precipitating causes must be identified and addressed. The most common precipitant for DKA is infection with other precipitating factors including acute illness, medications and inadequate insulin therapy (1).A 76 year-old woman with type 2 diabetes was transferred from her assisted living facility for hyperglycemia. This was her fifth admission in the last month and a half attributed to either hyperglycemia or DKA. Her medications included insulin glargine and insulin aspart. She mentioned compliance with her insulin as well as her diabetic diet. In the ER, her vitals were stable with physical examination showing an obese woman in no acute distress. Her labs showed a blood glucose of 780, an anion gap of 17 and positive serum ketones. Further investigation did not reveal a source of infection or ischemia. The patient was treated in the ICU with intravenous insulin and fluids with resolution of her ketoacidosis. The patient was discharged with a 67% increase in her prandial insulin. On further review, her facility had recently required safety needles to be used for insulin pens. Patient was asked to demonstrate her technique with observation that patient was not pushing down enough to allow for the needle to enter her skin with subsequent trapping of her insulin within the needle. Prior to discharge, she was educated on proper administration of her insulin and since her discharge, she has had no subsequent readmissions for hyperglycemia.Hospitals and long-term facilities are the primary utilizers of needles with a retractable safety shield. Reduction of accidental puncture, elimination of reuse of needles and helping patients overcome anxiety about needles are some of the key advantages of these needles. Upon application of pressure onto the skin, the automatic shield or plastic cannula retracts and thus hides the needle before, during and after the injection. The major disadvantage is insulin being deployed while the needle is outside the body if incorrectly applied. Therefore, appropriate administration must be taught to the patient, including perpendicular insertion of the needle into the subcutaneous tissue and ensuring a more firm surface by injecting into a lifted skin fold. Legislation in the US has been passed requiring safety-engineered devices when feasible.In situations where the safety-engineered devices can impair effectiveness or cause harm, alternative approaches can be utilized, including insulin syringes or self-administration of insulin along with safe work procedures (1).1. Yu Catherine H.Y.. “Safety” technology: a hidden cause of diabetic ketoacidosis. Canadian Medical Journal Journal. 2012 Mar 20;184(5):557–558.

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.

Dural sac localization using myelography and its application to the lumbosacral epidural in dogs.

Background:The techniques described for the identification of the lumbosacral (LS) epidural space in dogs do not guarantee the needle position or an accidental subarachnoid puncture, especially in small size dogs.Aim:To determine the relationship between body weight and the location of the dural sac (DS) using myelography in dogs, and to determine the possibility of subarachnoid puncture during LS epidural based on the position of the DS.Methods:Four masked observers evaluated 70 myelographic studies of dogs, annotating the vertebrae where the DS ended, if it was localized before or after the LS space, and if accidental subarachnoid puncture during LS epidural injection was possible (yes/no). Body weight (kg) was categorized into: less than 10 kg, between 10 and 20 kg, and more than 20 kg and was also converted to body surface area (BSA) as a continuous variable.Results:The DS ended at the LS space or caudally in 50% of dogs. There was a statistically significant difference between the position of the DS and the dog’s BSA (p = 0.001). The DS ended caudal to the LS space in 72.7% of dogs weighing <10 kg, in 25% of dogs between 10 and 20 kg and in 15% of dogs in the >20 kg category. The observers considered a possible subarachnoid puncture during LS epidural in 69.7% of patients <10 kg, 16.6% on those between 10 and 20 kg, and in 11.7% of the dogs >20 kg.Conclusion:The DS ended caudal to the LS space in almost 3/4 dogs in the <10 kg category, so accidental subarachnoid puncture during LS epidural is highly possible in this weight range.

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.

Anatomical variations of femoral vessels

Femoral triangle is an important site for various clinical procedures. Knowledge about anatomical variations of femoral vessels is important to prevent inadvertent damage during surgical procedures and for successful arterial and venous cannulation. It is an incidental finding in which profunda femoris artery originated just 1cm below inguinal ligament from lateral aspect of femoral artery (FA) in left femoral region of a middle aged Sri Lankan man which was observed during routine dissection. It was observed that FA crossed superficially over femoral vein (FV) in upper part of femoral triangle and FV was lying deep to FA in most part of femoral triangle. FV catheterization is necessary when there is no visible peripheral vein for cannulation or when rapid access to a large vein is needed. Complications may arise from accidental puncture of neighbouring structures. Ultrasonography should be used particularly for more difficult femoral vascular access. Even though variations are mostly incidental findings and being of general anatomical interest, knowledge of these variations appears to be mandatory for planning surgery and vascular interventions.

The incidence of post-dural puncture headache in the obese parturient compared to the non-obese parturient after an accidental dural puncture: a systematic review protocol.

The purpose of this systematic review is to determine if there is a difference in the incidence of post-dural puncture headache in the obese parturient compared to the non-obese parturient after an accidental dural puncture. Placement of an epidural catheter is a common technique to ease the pain of childbirth. One potential complication is a headache that occurs if the dura mater is accidentally punctured with the epidural needle during the procedure. Certain factors impact the likelihood of a postdural puncture headache after an accidental dural puncture in parturients. One potential factor is obesity. There is evidence to suggest that obesity lowers the risk of postdural puncture headache, although not all studies agree. There are no current or active systematic reviews that address whether or not obesity in parturients is protective against postdural puncture headache. Studies with parturients aged 18 to 45 who have had a documented accidental dural puncture with an epidural needle will be included in this review. Studies with parturients with a history of spinal surgery or pre-existing headache pathology will be excluded. Studies involving non-obstetrical patients will be excluded. A systematic search of MEDLINE, CINAHL Complete, Scopus, and Wiley Online Library will be conducted to identify studies on the topic of interest. Studies will be selected for review based on the inclusion criteria and will be appraised by two reviewers using the appropriate JBI standardized appraisal tool. 136047 (PROSPERO).

Effects of regional anesthesia techniques on local anesthetic plasma levels and complications in carotid surgery: a randomized controlled pilot trial

BackgroundThe ultrasound guided intermediate cervical plexus block with perivascular infiltration of the internal carotid artery (PVB) is a new technique for regional anesthesia in carotid endarterectomy (CEA). We conducted a pilot study investigating the effects of deep cervical block (DCB), intermediate cervical block alone (ICB) and PVB on perioperative complications in patients undergoing elective CEA. We hypothesized, that the ropivacaine plasma concentration is higher in patients receiving DCB compared to PVB and ICB.MethodsIn a randomized controlled pilot study thirty patients scheduled for elective CEA were randomly assigned into three groups: DCB receiving 20 mL ropivacaine 0.5% (n = 10), ICB receiving 20 mL ropivacaine 0.5% (n = 10) and PVB receiving 20 mL ropivacaine 0.5% and 10 mL ropivacaine 0,3% (n = 10). As primary outcome, plasma levels of ropivacaine were measured with high performance liquid chromatography before, 5, 10, 20, 60, and 180 min after the injection of ropivacaine. Secondary outcomes were vascular and neurological complications as well as patients’ and surgeons’ satisfaction. All analyses were performed on an intention-to-treat basis. Statistical significance was accepted at p < 0.05.ResultsNo conversion to general anesthesia was necessary and we observed no signs of local anesthetic intoxication or accidental vascular puncture. Plasma concentration of ropivacaine was significantly higher in the DCB group compared to PVB and ICB (p < 0.001) and in the PVB group compared to ICB (p = 0.008). Surgeons’ satisfaction was higher in the PVB group compared to ICB (p = 0.003) and patients’ satisfaction was higher in the PVB group compared to ICB (p = 0.010) and DCB group (p = 0.029). Phrenic nerve paralysis was observed frequently in the DCB group (p < 0.05). None of these patients with hemi-diaphragmatic paralysis showed signs of respiratory distress.ConclusionThe ultrasound guided PVB is a safe and effective technique for CEA which is associated with lower plasma levels of local anesthetic than the standard DCB. Considering the low rate of complications in all types of regional anesthesia for CEA, larger randomized controlled trials are warranted to assess potential side effects among the blocks.Trial registrationThe trial was registered at German Clinical Trials Register (DRKS) on 04/05/2019 (DRKS00016705, retrospectively registered).