Central Vein Access Research Articles

Evaluation of pediatric patients for intestinal transplantation in the modern era.

To review recent evaluations of pediatric patients with intestinal failure (IF) for intestinal transplantation (ITx), waiting list decisions, and outcomes of patients listed and not listed for ITx at our center. Retrospective chart review of 97 patients evaluated for ITx from January 2014 to December 2021 including data from referring institutions and protocol laboratory testing, body imaging, endoscopy, and liver biopsy in selected cases. Survival analysis used Kaplan-Meier estimates and Cox proportional hazards regression. Patients were referred almost entirely from outside institutions, one-third because of intestinal failure-associated liver disease (IFALD), two-thirds because of repeated infective and non-IFALD complications under minimally successful intestinal rehabilitation, and a single patient because of lost central vein access. The majority had short bowel syndrome (SBS). Waiting list placement was offered to 67 (69%) patients, 40 of whom for IFALD. The IFALD group was generally younger and more likely to have SBS, have received more parenteral nutrition, have demonstrated more evidence of chronic inflammation and have inferior kidney function compared to those offered ITx for non-IFALD complications and those not listed. ITx was performed in 53 patients. Superior postevaluation survival was independently associated with higher serum creatinine (hazard ratio [HR] 15.410, p = 014), whereas inferior postevaluation survival was associated with ITx (HR 0.515, p = 0.035) and higher serum fibrinogen (HR 0.994, p = 0.005). Despite recent improvements in IF management, IFALD remains a prominent reason for ITx referral. Complications of IF inherent to ITx candidacy influence postevaluation and post-ITx survival.

PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY IN SUBCLAVIAN VEIN STENOSIS CAUSED BY CENTRAL VENOUS CATHETERIZATION FOR HEMODIALYSIS ACCESS IN CHRONIC KIDNEY DISEASE PATIENTS

Introduction: The increased of central vein access for hemodialysis in chronic kidney disease patients has led to increase of side effect in clinically relevant stenosis of subclavian vein. One of therapeutic options to solve stenosis of subclavian vein is endovascular treatment Percutaneous Transluminal Angioplasty (PTA) . Objectives: To show our experience in treating subclavian vein stenosis using Endovacular treatment Percutaneous Transluminal Angioplasty (PTA). Materials and Methods: A retrospective study in 62 chronic kidney disease patients who undergo hemodyalisis with stenosis of subclavian vein treated with PTA in 3 hospitals in Surabaya from October 2017-October 2020 with range age 18-70 years was conducted . Results: We performed PTA for subclavian vein stenosis in 62 cases. Partial stenosis was found in 35 cases and total occlusion in 27 cases. For 27 total occlusion cases, 19 cases can still be opened, but 8 cases can’t be opened or recanalization and we drop out these patient. 54 cases (87%) were good and 8 cases (13%) can’t be open. The result of PTA in treating stenosis of subclavian vein was good. The result of reduced in arm swelling and using doppler USG follow up are 100%(54/54) after 1 month, 100%(54/54) after 3 months, 90.7% (49/54) after 6 months. Conclusion: Percutaneous Transluminal Angioplasty (PTA) is effective in treating subclavian vein stenosis reliefe its symptomps. The patency rate is 90.7% after 6 months post procedure of PTA.

Precise Terminology and Specified Catheter Insertion Length in Ultrasound-Guided Infraclavicular Central Vein Catheterization.

Background and Objectives: As the latest research encourages the ultrasound-guided infraclavicular central venous approach, due to the lateral puncture site displacement, in comparison to the anatomical landmark technique based on subclavian vein catheterization, the need to re-calculate the optimal catheter insertion length and possibly to rename the punctuated vessel emerges. Although naming a particular anatomical structure is a nomenclature issue, a suboptimal catheter position can be associated with multiple life-threatening complications and must be avoided. The main study objective is to determine the optimal catheter insertion length by the most proximal ultrasound-guided, in-plane infraclavicular central vein approach, to compare results with the anatomical landmark technique based on subclavian vein catheterization and to clarify the punctuated anatomical structure. Materials and Methods: 109 patients were enrolled in this study. All procedures were performed according to the same catheterization protocol. In order to determine optimal insertion length, chest X-ray scans with an existing catheter were performed. The definition of punctuated vessel was based on computer tomography and evaluated by radiologists. Independent predictors for optimal insertion length were identified, prediction equations were generated. Results: The optimal catheter insertion length is approximately 1.5 cm longer than estimated by Pere's formula and can be accurately calculated based on anthropometric data. Computed tomography revealed: five cases with subclavian vein puncture and three cases with axillary vein puncture. Conclusions: Even the most proximal ultrasound-guided infraclavicular central vein access does not guarantee subclavian vein catheterization. A more accurate term could be infraclavicular central venous access, with the implication that the entry point could be through either subclavian or axillary veins. The optimal insertion length is approximately 1.5 cm deeper than the length determined for the anatomical landmark technique based on subclavian vein catheterization.

Blood Culture Result Profile in Patients With Central Line-Associated Bloodstream Infection (CLABSI): A Single-Center Experience.

Background Central line-associated bloodstream infection (CLABSI) is among the most common bloodstream infections in the university hospital and intensive care unit settings. This study evaluated the routine blood test findings and microbe profiles of bloodstream infection (BSI) by the presence and types of central vein (CV) access devices (CVADs). Methods A total of 878 inpatients at a university hospital who were clinically suspected for BSI and underwent blood culture (BC) testing between April 2020 and September 2020 were enrolled. Data regarding age at BC testing, sex, WBCcount, serum C-reactive protein (CRP) level, BC test results, yielded microbes, and usage and types of CVADs were evaluated. Results The BC yields were detected in 173 patients (20%), suspected contaminating pathogens in 57 (6.5%), and 648 (74%) with a negative yield. The WBC count (p=0.0882) and CRP level (p=0.2753) did not significantly differ between the 173 patients with BSI and the 648 patients with negative BC yields. Among the 173 patients with BSI, 74 used CVADs and met the diagnosis of CLABSI; 48 had a CV catheter, 16 had CV access ports, and 10 had a peripherally inserted central catheter (PICC). Patients with CLABSI showed lower WBC counts (p=0.0082) and serum CRP levels (p=0.0024) compared to those with BSI who did not use CVADs. The most commonly yielded microbes in those with CV catheters,CV-ports, and PICC wereStaphylococcus epidermidis(n=9; 19%),Staphylococcus aureus(n=6; 38%), andS. epidermidis(n=8; 80%), respectively. Among those with BSI who did not use CVADs,Escherichia coli(n=31; 31%) was the most common pathogen, followed byS. aureus(n=13; 13%). Conclusion Patients with CLABSI showed lower WBC counts and CRP levels than those with BSI who did not use CVADs.Staphylococcus epidermidiswas among the most common microbes in CLABSI and accounted for the majority of yielded microbes in patients who used PICC.

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7

Interventions for treating catheter-related bloodstream infections in people receiving maintenance haemodialysis.

Patients with kidney failure require vascular access to receive maintenance haemodialysis (HD), which can be achieved by an arteriovenous fistula or a central venous catheter (CVC). CVC use is related to frequent complications such as venous stenosis and infection. Venous stenosis occurs mainly due to trauma caused by the entrance of the catheter into the venous lumen and repeated contact with the vein wall. A biofilm, a colony of irreversible adherent and self-sufficient micro-organisms embedded in a self-produced matrix of exopolysaccharides, is associated with the development of infections in patients with indwelling catheters.Despite its clinical relevance, the treatment of catheter-related bloodstream infections (CRBSIs) in patients receiving maintenance HD remains controversial, especially regarding catheter management. Antibiotic lock solutions may sterilise the catheter, treat the infection and prevent unnecessary catheter procedures. However, such treatment may also lead to antibiotic resistance or even clinical worsening in certain more virulent pathogens. Catheter removal and delayed replacement may remove the source of infection, improving infectious outcomes, but this approach may also increase vascular access stenosis, thrombosis or both, or even central vein access failure. Catheter guidewire exchange attempts to remove the source of infection while maintaining access to the same vein and, therefore, may improve clinical outcomes and preserve central veins for future access. To assess the benefits and harms of different interventions for CRBSI treatment in patients receiving maintenance HD through a permanent CVC, such as systemic antibiotics alone or systemic antibiotics combined with either lock solutions or catheter guidewire exchange or catheter replacement. We searched the Cochrane Kidney and Transplant Register of Studies up to 21 December 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. We included all randomised controlled trials (RCTs) and quasi-RCTs evaluating the management of CRBSI in permanent CVCs in people receiving maintenance HD. Two authors independently selected studies for inclusion, assessed their risk of bias, and performed data extraction. Results were expressed as risk ratios (RR) or hazard ratios (HR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with their 95% confidence intervals (CI). The certainty of the evidence was assessed using GRADE. We identified two RCTs and one quasi-RCT that enrolled 760 participants addressing the treatment of CRBSIs in people (children and adults) receiving maintenance HD through CVC. No two studies compared the same interventions. The quasi-RCT compared two different lock solutions (tissue plasminogen activator (TPA) and heparin) with concurrent systemic antibiotics. One RCT compared systemic antibiotics alone and in association with an ethanol lock solution, and the other compared systemic antibiotics with different catheter management strategies (guidewire exchange versus removal and replacement). The overall certainty of the evidence was downgraded due to the small number of participants, high risk of bias in many domains, especially randomisation, allocation, and other sources of bias, and missing outcome data. It is uncertain whether an ethanol lock solution used with concurrent systemic antibiotics improved CRBSI eradication compared to systemic antibiotics alone (RR 1.61, 95% CI 1.16 to 2.23) because the certainty of this evidence is very low. There were no reported differences between the effects of TPA and heparin lock solutions on cure rates (RR 0.92, 95% CI 0.74 to 1.15) or between catheter guidewire exchange versus catheter removal with delayed replacement, expressed as catheter infection-free survival (HR 0.88, 95% CI 0.43 to 1.79). To date, no results are available comparing other interventions. Outcomes such as venous stenosis and/or thrombosis, antibiotic resistance, death, and adverse events were not reported. Currently, there is no available high certainty evidence to support one treatment over another for CRBSIs. The benefit of using ethanol lock treatment in combination with systemic antibiotics compared to systemic antibiotics alone for CRBSIs in patients receiving maintenance HD remains uncertain due to the very low certainty of the evidence. Hence, further RCTs to identify the benefits and harms of CRBSI treatment options are needed. Future studies should unify CRBSI and cure definitions and improve methodological design.

Spectrum of Interventional Procedures During Hybrid Central Line Placement in Pediatric Intestinal Rehabilitation Patients With End-Stage Vascular Access.

BackgroundLoss of available central vein access sites for parenteral nutrition delivery represents one of the main indications for intestinal transplantation in children with intestinal failure. Placement of central venous catheters can be challenging in advanced loss of patent venous pathways. We recently described the hybrid technique (interventional plus surgical approach) of central line placement in children. The aim of this study was to describe and analyze the interventions used during the hybrid procedures regarding feasibility, safety and outcome.MethodsWe retrospectively analyzed the course of all children in our intestinal rehabilitation program undergoing hybrid central line placement. We evaluated patients' conditions, interventional techniques and surgical peculiarities as well as outcome.Results203 children were treated in our intestinal rehabilitation program between 2010 and 2021. Due to loss of venous access, hybrid technique was performed in 53 children during 76 interventions. In 40 cases the same vessel was reused via Seldinger technique. Among the 30 ultrasound-guided new vessel punctures, 12 were performed by puncture of collateral vessels. Extended interventions due to thoracic central venous obstruction and/or thrombosis requiring additional access via a femoral vein for rehabilitation of the vascular system was performed during 29 procedures including catheter extraction (1), angioplasties (18), stent placement (1), revascularization (5) and thrombectomy (4). Placement of a central line was not possible in 6 children which eventually underwent extended thoracic/vascular surgery: in three children the previously placed catheter could not be removed, in one child, placement of a thrombectomy-catheter was not possible because of inferior vena cava occlusion, and in two children, revascularization failed. Intestinal transplantation was considered in one patient because of impending loss of vascular access. Two self-limiting minor extravasations and one intervention-associated pericardial effusion occurred.ConclusionsHybrid interventions for central venous catheter placement and vascular rehabilitation enable a high success rate in children with intestinal failure and end-stage vascular access, circumventing the need for intestinal transplantation or advanced surgery. The relevant procedures are complex and require a foresighted and individualized approach with a wide range of interventional techniques. If performed with expertise, this combined interventional/surgical approach is feasible and safe.

Axillary vein access using ultrasound guidance, Venography or Cephalic Cutdown-What is the optimal access technique for insertion of pacing leads?

We reviewed the different approaches used for central vein access during insertion of cardiac implantable electronic devices. The benefits and hazards of each approach (cephalic vein cutdown, axillary vein cannulation using venography and ultrasound) are discussed. Each approach has its advantages and hazards that need to be considered for the individual patient and balanced against the skills of the operator. The benefits of ultrasound guided venous access in reducing radiation exposure to the patient and implanter, avoiding the need for angiographic contrast and in minimizing the risk of pneumothorax and inadvertent arterial puncture are highlighted. Trainees should be taught each approach to deal with patient variability. Ultrasound guidance should be considered as a mainstream option for most patients.

Comparison of Central Venous Port Procedures Between Puncture vs. Cut-down and Residents vs. Senior Surgeons.

To compare operative results between venous puncture (P) with real-time ultrasonography vs. cut-down (CD) with preoperative ultrasonography for totally implantable central vein access device (TICVAD) implantation performed by residents (R) vs. senior surgeons (S). Adult oncologic patients (n=268) undergoing TICVAD implantations were retrospectively compared between 172 Ps and 96 CDs. Then, we compared Ps performed by R (P-R, n=131) and S (P-S, n=41) and CDs performed by R (CD-R, n=59) and S (CD-S, n=37). Median operation times were 40 min in the P group and 53.5 min in the CD group, and times were significantly shorter for P-S and CD-S. Completion rates were comparable for each method and each surgeon. Intraoperative complication rates were 3.8% (P-R), 2.4% (P-S), and 0% (CD-R and CD-S). P with real-time ultrasonography did not avoid complications compared to CD with preoperative ultrasonography. The latter performed safely even by residents.

The impact of taurolock versus heparin lock for the maintenance of central vein catheters patency in pediatric tertiary care hospitals

Background and AimCentral vein access is a common procedure in infants and neonates. In this regard, cutdown is a common central venous access technique. However, it is associated with complications, including catheter occlusion, infection, and spontaneous withdrawal. Catheter occlusion is a common complication of the cutdown procedure and causes catheter dysfunction and subsequent catheter removal. In this study, we compared the effect of heparin lock with Taurolock on the maintenance of central vein catheter potency placed in the greater saphenous vein at the saphenofemoral junction and their subsequent complications.Materials and MethodsThe children admitted to the pediatric hospital who required central vein access between December 2015 and July 2019 were recruited. There were two groups of patients. The first group received 0.5 mL Taurolock solution. The solution contains (cyclo)-taurolidine, heparin 500 IU/mL, and citrate (4%) before the catheter gets locked (Taurolock group). Another group received 0.5 mL heparin (contains 500 IU/mL heparin) before the catheter lock (heparin lock group). After the treatment period, the average duration of catheter usage and heparin-induced bleeding complications were evaluated.ResultsThe average duration of catheter function was 13.4 days and 9.3 days in the Taurolock group, and the heparin lock group, respectively. The coagulation tests were performed on 179 patients (33.9%) during hospitalization, no heparin-induced coagulopathies were reported.ConclusionUsing Taurolock after catheter use could significantly reduce catheter occlusion and increase the duration of catheter function. Taurolock reduces costs, prevents delays in treatment, and decreases pain sensation and discomfort in patients.

Review of simulation model for education of point-of-care ultrasound using easy-to-make tools

Point-of-care ultrasound (POCUS) is a powerful diagnostic tool and provides treatment guidelines in acute critical settings. However, the limitation of using POCUS is operator dependent. Appropriate and validated training for acquiring and using skills in practice must be conducted before using POCUS in clinical settings in order to keep patients safe. Simulation education models have been introduced as a way to solve and overcome these concerns. However, the commercial simulator with sufficiently secured fidelity is expensive and not always available. This review focused on the inexpensive and easily made simulators for education on POCUS in critical specific situations related to the airway, breathing, circulation, and disability. We introduced the simulators that used non-infectious materials, with easily transportable features, and that had a sonographic appearance reproducibility similar to human tissue. We also introduced the recipe of each simulator in two parts: Materials surrounding disease simulators (surrounding materials) and specific disease simulators themselves (target simulators). This review article covered the following: endotracheal or oesophageal intubation, lung (A-lines, B-lines, lung sliding, and pleural effusions such as hemothorax), central vein access, pericardial fluid (cardiac tamponade), the structure related to the eyes, soft tissue abscess, nerve (regional nerve block), and skull fracture simulators.

New Insights Into the Indications for Intestinal Transplantation: Consensus in the Year 2019.

In 2001, a Statement was published that described indications for intestinal transplantation in patients with intestinal failure expected to require parenteral nutrition indefinitely. Since 2001, advances in the management of intestinal failure including transplantation and patient survival, both on extended parenteral nutrition and after transplantation, have improved, leading to a reduction in the number of intestinal transplants worldwide from a peak of 270 per year in 2008 to 149 per year in 2017. These changes suggest that the original 2001 Statement requires reassessment. All patients with permanent intestinal failure should be managed by dedicated multidisciplinary intestinal rehabilitation teams. Under care of these teams, patients should be considered for intestinal transplantation in the event of progressive intestinal failure-associated liver disease, progressive loss of central vein access, and repeated life-threatening central venous catheter-associated infections requiring critical care. Additional indications for transplantation include large desmoid tumors and other intra-abdominal tumors with reasonable expectation of posttransplant cure, extensive mesenteric vein thrombosis and intestinal infarction, total intestinal aganglionosis, and nonrecoverable congenital secretory diarrhea. Quality of life typically improves after successful intestinal transplantation and may support the decision to proceed with transplantation when other indications are present. However, the requirement for life-long immunosuppression and its associated side effects preclude intestinal transplantation if motivated only by an expectation of improved quality of life. Increasing experience with intestinal transplantation and critical appraisal of transplant outcomes including graft survival and patient quality of life together with potential advances in immunosuppression can be expected to influence transplant practices in the future.

Hepatic extravasation complicated by umbilical venous catheterization in neonates: A 5-year, single-center experience

BackgroundCare of newborns in the neonatal intensive care unit generally involves umbilical venous catheterization (UVC) for central vein access to enable medical needs. The study aimed to evaluate the sonographic appearance, risk factors, and outcomes of UVC-related hepatic extravasation (HE) in neonates. MethodsA 5-year retrospective study where 33 neonates were enrolled with a diagnosis age ranging from 2 to 25 days. 78.8% of the subjects had UVC malpositioning shown on initial radiography. All neonates sonographically diagnosed with HE, and follow-up ultrasound (US) was performed. ResultsThe main findings of HE on US were hyperechoic or heterogeneous lesions of a lobulated (51.7%) or wedge shape (48.3%), located mainly in the left lobe (72.7%). The mean time to resolution of HE was 2.25 months. Seven (21.2%) patients showed hepatic vascular thrombosis at follow-up. Two (6%) patients had abnormal liver function, which subsequently normalized. ConclusionMalposition of the UV catheter was the predisposing factor for UVC-related HE in neonates. US facilitates detection of UVC malpositioning and diagnosis of HE, as well as delayed complications. A shorter duration of UVC placement is associated with favorable outcomes of UVC-related HE in neonates.

Complications analysis of subcutaneous venous access port for chemotherapy in patients with gastrointestinal malignancy

To describe and analyze the complications of subcutaneous venous access port for patients with gastrointestinal malignancy. Data of 1 912 patients with gastrointestinal malignancy who accepted chemotherapy in our department via subcutaneous venous access ports, including 127 cases in upper arm, 865 cases in subclavicular vein and 920 cases in internal jugular vein, from June 2007 to April 2016 were analyzed retrospectively. Associated complications and risk factors were emphatically investigated. Postoperative complications were confirmed in 233 patients(12.2%), and complication morbidity was 37.0%(47/127), 15.5%(134/865), 6.7%(62/920) in upper arm group, subclavicular vein group, internal jugular vein group respectively, whose difference was statistically significant (χ2=71.060, P=0.000). Sixty-one(3.2%) patients developed early complications (in the day of insertion, including catheter dislocation, pneumothorax, arterial damage). Early complication morbidity of upper arm group (14.2%, 18/127) was higher as compared to subclavicular vein group (3.4%, 29/865) and internal jugular vein group(1.5%, 14/920) with significant difference (χ2=57.867, P=0.000). Postoperative long-term complications (catheter dislocation, thrombosis, pinch-off syndrome, infusion base exposure, catheter detachment) were found in 182(9.5%) patients. Morbidity of long-term complication was 5.2%(48/920) in internal jugular vein group, which was significantly lower than 22.8% (29/127) in upper arm group and 12.1% (105/865) in subclavicular vein group with statistically significant difference (χ2=50.828, P=0.000). Multivariate analysis indicated that subclavicular vein intubation (OR=0.536, 95%CI: 0.341 to 0.843; P=0.007 OR=0.156, 95%CI: 0.096 to 0.253, P=0.000), internal jugular vein intubation (OR=0.156, 95%CI: 0.096 to 0.253, P=0.000), operation time <40 minutes (OR=0.458, 95%CI: 0.342 to 0.613, P=0.000) and standardized training (OR=0.233,95%CI: 0.171 to 0.318, P=0.000) were protective factors of postoperative complication; besides, subclavicular vein intubation (OR=0.458, 95%CI: 0.342 to 0.613, P=0.000), internal jugular vein intubation (OR=0.233, 95%CI: 0.171 to 0.318, P=0.000) and standardized training (OR=0.313, 95%CI: 0.173 to 0.568, P=0.000) were protective factors of thrombosis. Subcutaneous venous access port implantation is a preferable access to central vein. Appropriate intubation approach and standardized training may reduce postoperative complications effectively. Internal jugular vein approach is safer and more reliable than upper arm vein and subclavian vein approach.

The New Kidney Donor Allocation System and Implications for Anesthesiologists.

Given potential disparity and limited allocation of deceased donor kidneys for transplantation, a new federal kidney allocation system was implemented in 2014. Donor organ function and estimated recipient survival in this system has implications for perioperative management of kidney transplant recipients. Early analysis suggests that many of the anticipated goals are being attained. For anesthesiologists, implications of increased dialysis duration and burdens of end-stage renal disease include increased cardiopulmonary disease, challenging fluid, hemodynamic management, and central vein access. With no recent evidence to guide anesthesia care within this new system, we describe the kidney allocation system, summarize initial data, and briefly review organ systems of interest to anesthesiologists. As additional invasive and echocardiographic monitoring may be indicated, one consideration may be development of a dedicated anesthesiology team experienced in management and monitoring of complex patients, in a similar manner as has been done for liver transplant recipients.

Features of Life Quality in Long-Term Survivors of Intestinal Transplantation in Childhood

Background: Improving outcomes after intestinal transplantation have produced an expanding cohort of long-term survivors. Aim: In order to gain insight into life quality of this group, we reviewed the status of 48 infants and children who received an intestinal transplant at least 5 years before analysis and who possessed a fully functional graft, i.e. receiving total enteral nutrition with no central vein access. Results: Pre-transplant diagnosis was short bowel in 88% while the remainder had a functional form of intestinal failure. Median age at intestinal transplantation was 1.8 years (0.5 to 16.5) and included a liver graft in 75%, a multi-visceral graft in 10%, and a colon graft in 25%. Mean age at analysis was 12.5±4.7 years, giving a post-transplant survival of 8.7±2.4 years. Primary immunosuppression was tacrolimus in 66%, tacrolimus-sirolimus in 22%, and tacrolimus-mycophenolate in 10% with 1 fully tolerant patient taking no immunosuppression. Mean daily drugs consumed was 10±5. Anti-diarrheal agents were used regularly by 55% and anti-hypertensive drugs by 28%. Estimated GFR (cystatin C-sCr) was 70±19 mL/min/1.73 M2. Dietary restriction based on food allergy was present in 33% while supplemental feeding, generally via gastrostomy, continued in 38%. Mean height and weight z-scores were −1.24±1.83 and −1.10±1.45, respectively. Significant developmental delays were present in 29%, generally recognized before transplant and most often associated with marked prematurity. Of the remaining patients, 60% had special schooling arrangements, most notably individual educational programs. Conclusion: Although intestinal transplantation is a life-saving operation for patients experiencing life-threatening complications of intestinal failure, numerous threats to life-quality persist despite total independence from parenteral nutrition. Some of these threats originate before transplant and are inherent to the underlying condition whereas others are more directly related to the transplant itself.

Success rate and complications of internal jugular vein catheterization with and without ultrasonography guide.

Central venous catheterization (CVC) is an important procedure in emergency departments (EDs). Despite existence of ultrasonography (US) devices in every ED, CVC is done using anatomical landmarks in many EDs in Iran. This study aimed to compare the traditional landmark method vs. US-guided method of CVC placement in terms of complications and success rate. In this randomized controlled trial, patients who were candidate for internal jugular vein catheterization, and referred to Baqiyatallah Hospital ED were randomly allocated into US-guided CVC and anatomical landmarks guided CVC groups. Central vein access time, number of attempts, success rate, and complications in each group were evaluated. Mann-Whitney U, chi-square and Fisher exact tests along with Pearson and Spearman correlation coefficients were used to analyze the data. Out of 100 patients, 56 were male and 44 were female. No significant differences were found between the US-guided and traditional landmark methods of CVC insertion in terms of age, gender, BMI, and site of catheter insertion. The mean access time was significantly lower in the US-guided group (37.12 ± 17.33 s vs. 63.42 ± 35.19 s, P < 0.001). The mean number of attempts was also significantly lower in the US-guided group (1.12 ± 0.3 vs. 1.58 ± 0.64 times, P < 0.001). Eighty-eight percent of patients in the US-guided group were catheterized in the first attempt, while 50% of patients in the traditional landmark group were catheterized in the second or more attempts (P < 0.001). The success rate was 100% in the US-guided group, while it was 88% in the landmark group (P = 0.013). Moreover, the rate of complications was significantly lower in the US-guided group (4% vs. 24%, P = 0.004). The US-guided method for CVC placement was superior to the traditional landmark method in terms of access time, number of attempts, success rate, and fewer complications.

Supraclavicular course of the cephalic vein

Introduction: Vascular access for transvenous pacemaker and cardioverter defibrillator implants is frequently obtained by using the cephalic cutdown technique. Sometimes anatomical variations may limit insertion of one or several leads. We describe a case of a patient with an anomalous supraclavicular course of the left cephalic vein. Case Report: A 61-year-old male with background of ischemic heart disease, hypertension, diabetes mellitus, obstructive sleep apnea and dyslipidemia, was referred to our institution after four months of recurrent syncopal episodes. A bradycardia-tachycardia syndrome was diagnosed and decided to proceed with permanent pacemaker implantation. Through a cutaneous incision in the left deltopectoral groove, we dissected the tissue planes until the left cephalic vein became visible. Fluoroscopy in anterior-posterior projection showed clear supraclavicular course of the cephalic vein. This access was abandoned by removing both wires and ligating the proximal end of the cephalic vein. Through a fluoroscopy/ venogram guided axillary puncture using the modified Seldinger technique and the retained wire technique, double central vein access was secured, allowing the passage of right atrial and ventricular leads. A dual chamber pacemaker was implanted. Conclusion: Although the supraclavicular course of the cephalic vein is a rare anatomical variant, it is important to recognize its presence as it may lead to potential complications related to lead dysfunction, erosion or collateral vascular damage if used as an access for permanent lead placement. Alternative central vein access is strongly recommended in such cases.

Erratum to: The central vein access port and catheter in outpatient chemotherapy for colorectal cancer: a retrospective study of 101 patients

Erratum to: The central vein access port and catheter in outpatient chemotherapy for colorectal cancer: a retrospective study of 101 patients

A prospective observational study on 249 subcutaneous central vein access ports in a Swedish county hospital

Background. Reliable central vein access is a fundamental issue in modern advanced oncological care. The aim of this study was to determine the incidence of complications and patient perception regarding central vein access ports. Methods. We prospectively studied 249 single lumen access ports implanted between 1 July 2008 and 15 March 2010 in a mixed patient population at a 500-bed secondary level hospital in Sweden. We determined the number of catheter days, infection rate and mechanical complications, as well as patient satisfaction regarding the access port, over a six-month follow-up period. Results. Two hundred and forty-four different patients received 249 ports yielding a total of 37 763 catheter days. Ultrasound and fluoroscopic guidance was used in 98% of procedures. Vein access was obtained percutanously by an anaesthesiologist in all cases. There was no case of pneumo- or haemothorax. The incidence of catheter-related bloodstream infection, was 0.05/1000 catheter days and the incidence of pocket/tunnel infection was 0.39/1000 catheter days. Clinically apparent deep vein thrombosis occurred in four patients (1.6%). Patient satisfaction was overall high. Conclusion. These results confirm that our team-based approach with written easily accessible evidence-based guidelines and a structured education programme leads to a very low complication rate and a high degree of patient satisfaction.