Cannulation Difficulty Research Articles

Flexible endoscopy for management of intraventricular brain tumors in patients with small ventricles.

Endoscopic surgery is generally withheld in patients with small ventricles due to difficulties in ventricular cannulation and intraventricular manipulation. The effectiveness of flexible endoscopy for management of intraventricular brain tumors in patients with small ventricles was evaluated. Forty-five patients who underwent endoscopic surgery with a flexible endoscope for intraventricular brain tumors were divided into small-ventricle and ventriculomegaly groups according to the frontal and occipital horn ratio (FOR). Retrospective review of these cases was performed and achievement of surgical goals and morbidity were assessed. Among the 45 patients, there were 14 with small ventricles and 31 with ventriculomegaly. In the smallventricle group, targeted tumors were located in the suprasellar region in 12 patients and in the pineal region in 2. In the ventriculomegaly group, tumors were located in the pineal region in 15 patients, in the suprasellar region in 9, in the lateral ventricle in 4, in the midbrain in 2, and in the fourth ventricle in 1. In the small-ventricle group, ventricular cannulation was successful and the surgical goals were accomplished in all patients. In ventriculomegaly group, sampling of the tumor was not diagnostic due to intraoperative hemorrhage in 1 patient. There were no significant differences in the rate of achieving the surgical goals or the morbidity between the 2 groups. Endoscopic surgery using a flexible endoscope is useful for management of intraventricular brain tumors in patients with small ventricles. A flexible endoscope allows excellent maneuverability in introducing the device into the lateral ventricle and manipulating through small ventricles.

English

Spinal Muscular Atrophy (SMA) is a rare genetic disease characterized by progressive degeneration of spinal cord motor neurons resulting in hypotonic muscle weakness.1 Out of the four types, type I is the most severe, presenting at 0 to 6 months. This is the most challenging type for anaesthetic management due to muscular weakness, airway difficulties, hyper sensitivity to non depolarising muscle relaxants, risk of hyperkalemia and difficulty in intravenous cannulation. 3 Here we present a case of SMA type I infant posted for percutaneous endoscopic gastrostomy (PEG) tube insertion under total intravenous anaesthesia (TIVA).

PS106. Aneurysm Plication Extends Life of Autologous Dialysis Fistula without Compromising Patency

The use of a native arteriovenous fistula (AVF) for dialysis is associated with fewer overall complications, and preserving long-term patency is a priority. The purpose of this study is to compare the patency and number of secondary interventions required of AVF when aneurysms are repaired with interposition prosthetic grafting (IG) vs aneurysm plication (PC). Fourteen patients with symptomatic aneurysms (15) of upper extremity autologous AVFs were treated with PC (eight) and IG (seven) between July 2007 and November 2013 at a single institution. The indications for operation were cutaneous thinning, ulceration, bleeding, and difficulty in cannulation. Patient characteristics, type of repair, patencies, and number of secondary interventions were recorded and analyzed. Fourteen consecutive patients (nine men) with mean age of 48 years, underwent 15 aneurysm repairs. Five patients (33%) had radiocephalic, nine (60%) brachiocephalic, and one (7%) brachiobasilic AVF with the mean follow-up of 9 months. Eight aneurysms (53%) underwent plication vs seven (47%) interposition grafts. The average diameter of the aneurysm was 2.6 cm (IG) and 2.8 cm (PC) (not significant). At 6 months of follow-up, the patency for PC was 62.5% vs 57.1% for the IG group (P > .4). One IG was excised due to infection and another was lost due to an unrelated death. Two patients in the PC group were converted to IG due to aneurysm extension. Overall, IG patients required eight times more procedures (five dialysis catheters and three endovascular interventions) vs 1 intervention for the PC group (P < .01). Preliminary results show that aneurysm PC extends the life of the native fistula and requires fewer interventions to maintain patency. When possible, this method should be considered as the repair procedure of choice for AVF aneurysms.

Endovascular techniques for cannulation difficulties in dialysis access.

Although the arteriovenous fistula (AVF) is the access of choice for dialysis, its success as an access is limited by its high rate of failing to mature and its development of venous stenoses. This makes cannulation difficult or even impossible for dialysis staff. A variety of endovascular techniques exist for improving cannulation rates in AVFs. These include coil embolization of tributaries and balloon-assisted maturation in immature fistulae and fistuloplasty, stents and thrombus removal in mature failing access. This article aims to discuss the methods and evidence related to these techniques.

Percutaneous Coronary Intervention of Anomalous Right Coronary Artery Arising from the Left Coronary Cusp using an Undersized Judkins Catheter through Transradial Route

Coronaries with anomalous origin are difficult to visualize on coronary angiography. Percutaneous coronary intervention (PCI) is a difficult procedure in these vessels because of difficulty in cannulation and poor guide support. The case of a 54-year-old gentleman who presented with an acute inferior wall myocardial infarction from occlusion of an anomalous right coronary artery arising from the left coronary cusp is described.

Arteriovenous fistula (AVF) monitoring and surveillance

Abstract An arteriovenous fistula (AVF) is created by direct anastomosis between an artery and adjacent vein which leads to flow of blood from artery directly into the vein. A well functioning and patent AVF is essential for optimum delivery of hemodialysis and hence it is important to assess the AVF for any signs of loss of patency (stenosis/thrombosis) on a regular basis. Methods of AVF monitoring include physical examination and other features like difficulty in AVF cannulation due to poor blood flow, clot aspiration or prolonged bleeding from the AVF site post hemodialysis. Methods of AVF surveillance include access blood flow, venous pressure and Doppler ultrasound etc. Both physical examination and investigations have complimentary role in this field and it is necessary that adequate stress is given on monitoring on a continuous basis. Access blood flow and intra-access pressures have role in confirming any abnormal physical examination finding.

A novel technique for catheter engagement of protruding aorto‐ostial stent

We present a case of stenoses in the right coronary artery with a previously deployed stent showing gross protrusion into the aorta. Despite difficulty in cannulation of a guiding catheter into the coronary artery, percutaneous intervention was accomplished using a novel technique to engage the protruding stent.

Cannulation time is a more accurate measure of cannulation difficulty in endoscopic retrograde cholangiopancreatography than the number of attempts.

Background: Cannulation of the common bile duct (CBD) is the initial and sometime challenging step in endoscopic retrograde cholangiopancreatography (ERCP) procedure. Endoscopists often use cannulation attempts and cannulation time to grade cannulation difficulty, but a standard system has yet to be established. The objective of this study was to compare cannulation times with numbers of cannulation attempts, as measures of cannulation difficulty.Methods: We conducted a prospective study in a tertiary referral center, enrolling 58 patients who were undergoing ERCP for a variety of indications. Cannulation time and the number of cannulation attempts were recorded for each patient. A subset of 14 ERCPs had two observers assessing attempts at cannulation. Cannulation time, number of attempts and inter-observer variability in assessment of attempts were compared and studied.Results: The degree of agreement between two the methods (cannulation times and number of cannulation attempts) was unacceptable. There were considerable discrepancies between attempt tallies from two observers but the mean difference was statistically insignificant.Conclusion: The grade of cannulation difficulty for a given ERCP procedure may differ when different methods are used (total cannulation time vs number of attempts); thus, grading by different methods should not be used interchangeably. Cannulation time is a more objective and more accurate assessment tool for grading cannulation difficulty than the number of attempts to cannulate the papilla.

Ascending Aortic Cannulation in Acute Type A Dissection Repair

Femoral and axillary cannulation for arterial inflow in acute type A aortic dissection are the most commonly used cannulation strategies in current practice. More recently, our group and others have successfully used a central cannulation technique with excellent results. Although this approach has been described, specific technical details have not been clearly defined. In addition, the ideal anatomic characteristics of different types of aortic dissections amenable to central cannulation have not been delineated. The purpose of this brief communication is to describe the technical and procedural details specific to cannulation of the dissected ascending aorta and to propose a classification scheme of ascending aortic dissection anatomy based on difficulty of central cannulation.

Difficult Arterial Cannulation in Children

Cuper, N. J.*; De Graaff, J. C.†; Hartman, B. J.†; Verdaasdonk, R. M.‡; Kalkman, C. J.† Author Information

Endoscopic retrograde cholangiopancreatography under moderate sedation and factors predicting need for anesthesiologist directed sedation: A county hospital experience.

To evaluate variables associated with failure of gastroenterologist directed moderate sedation (GDS) during endoscopic retrograde cholangiopancreatography (ERCP) and derive a predictive model for use of anesthesiologist directed sedation (ADS) in selected patients. With institutional review board approval, we retrospectively analyzed consecutive records of all patients who underwent ERCPs between July 1, 2009 to October 1, 2011 to identify patient related and procedure related factors which could predict failure of GDS. For patient related factors, we abstracted and analyzed data regarding the age, gender, ethnicity, alcohol and illicit drug use habits. For procedure related factors, we abstracted data regarding initial or repeat procedures, indication for performing ERCP, the interventions performed during ERCP, and the grade d difficulty of cannulation as defined in the American Society for Gastrointestinal Endoscopy guidelines. Our outcome of interest was procedural success. If the procedure was not successful, the reasons for failure of procedures were recorded along with immediate post procedure complications. Multivariate analysis was then performed to define factors associated with failure of GDS and a model constructed to predict requirement of ADS. Fourteen percent of patients undergoing GDS could not complete the procedure due to intolerance and 2% due to cardiovascular complications. Substance abuse, male gender, black race and alcohol use were significant predictors of failure of GDS on univariate analysis and substance abuse and higher grade of procedure remained significant on multivariate analysis. Using our predictive model where the presence of substance abuse was given 1 point and planned grade of intervention was scored from 1-3, only 12% patients with a score of 1 would require ADS due to failure of GDS, compared to 50% with a score of 3 or higher. We conclude that ERCP under GDS is safe and effective for low grade procedures, and ADS should be judiciously reserved for procedures which have a higher risk of failure with moderate sedation.

Indomethacin prevents post-ERCP pancreatitis in selected high-risk patients

BackgroundPancreatitis is one of the major complications of cholan-giopancreatography (ERCP). It occurs in 1–10 % ofpatients but the incidence may reach 25 % in high-riskpatient populations. Generally post-ERCP pancreatitis(PEP) is mild, but moderate or severe pancreatitis (pan-creas necrosis, pseudocyst formation, need of surgicalintervention, long hospitalization) may arise in 0.5 % ofcases [1, 2].The most common risk factors for this complication areboth patient-related and procedure-related: younger age,female gender, prior ERCP-induced pancreatitis, sphincterof Oddi dysfunction, pancreas divisum, difficulty of can-nulation, biliary sphincterotomy or pancreatic opacification[3]. Although some randomized clinical trials (RCTs) haveshown a potential benefit of gabexate mesilate andsomatostatin in preventing post-ERCP pancreatitis, thereare few data to recommend the use of these drugs; more-over, they require continuous infusion and are quiteexpensive [4, 5].A few RCTs have demonstrated a potential role ofnonsteroidal anti-inflammatory drugs (NSAIDs) as pre-vention for post-ERCP pancreatitis, but before introducingthese prophylactic strategies in clinical practice, morestudies are needed [6, 7].SummaryElmunzer et al. conducted a multicenter, randomized,placebo-controlled, double-blind clinical trial comparingthe use of a single dose of rectal indomethacin versusplacebo for the prevention of post-ERCP pancreatitis inhigh-risk patients. Patients were considered eligible, if theymet at least one major criteria: (clinical suspicion ofsphincter of Oddi dysfunction, a history of PEP, pancreaticsphincterectomy, precut sphincterectomy, more than eightcannulation attempts, pneumatic dilatation of an intactbiliary sphincter or ampullectomy) or two or more minorcriteria (age less than 50 and female gender, a history ofrecurrent pancreatitis, three or more injections of contrastagent into the pancreatic duct, excessive injection of con-trast agent resulting in opacification of pancreatic acini, orthe acquisition of a cytologic specimen from the pancreaticduct using a brush). The main exclusion criteria were:active pancreatitis, contraindication to the use of NSAIDs(creatinine level [1.4 mg per deciliter, or active pepticulcer disease), pre-existing therapy with NSAIDs (exceptfor cardioprotective aspirin), and low risk of post procedurepancreatitis (chronic calcific pancreatitis, biliary stentexchange). After ERCP had been performed, a total of 602patients were randomized to receive either 100 mg of rectalindomethacin or a placebo immediately after the proce-dure. The primary outcome was the development of PEPdefined as new-onset upper abdominal pain associated withan elevation of pancreatic enzymes C3 URL, and hospi-talization for at least two nights. The secondary outcomewas the development of moderate or severe post-ERCPpancreatitis. Patients who were discharged after anuneventful procedure were contacted by telephone after5 days, and again after 30 days to assess for delayedadverse events, and to determine the severity of post-ERCP

Difficult arterial cannulation in children: is a near-infrared vascular imaging system the answer?

Arterial cannulation is a common anaesthetic procedure that can be challenging and time-consuming in small children. By visualizing the position of the radial artery, near-infrared vascular imaging systems (NIRVISs) might be of assistance in arterial cannulation. The present study evaluates the effectiveness of an NIRVIS in arterial cannulation in infants. An observational study was conducted in patients up to 3 yr old, undergoing arterial cannulation before cardiothoracic surgery. Arterial cannulation was performed as usual in 38 patients, and subsequently with the NIRVIS in 39 patients. The time to successful cannulation was 547 s (171-1183) without and 464 s (174-996) with the NIRVIS (P=0.76) and the time to first flashback of blood was 171 s (96-522) and 219 s (59-447), respectively (P=0.38). There was a tendency in favour of the NIRVIS in success at first attempt: 12/38 and 7/39, respectively (P=0.29) and in the number of punctures: 6 (2-12) and 3 (1-7), respectively (P=0.10). The present study did not show a significant clinical improvement when NIR light was used during arterial cannulation in small children. There is a large difference between time to first flashback of blood and time to successful cannulation, indicating that inserting the cannula, and not localizing the artery, is the main difficulty in arterial cannulation in children.

Arteriovenous Fistula Failure: Is There a Role for Accessory Draining Vein Embolization?

Arterio-venous fistulae (AVFs) are accepted as the best form of haemodialysis vascular access (VA) but are plagued by high primary failure. Accessory drainage veins (ADVs) may account for up to 40% of these failures. Furthermore, they may also lead to low flow in 'mature' AVFs. We analysed the results of 42 patients who underwent endovascular coiling of ADVs at our centre over a 4-year period. Indications were failure to mature in 34%, low flow or cannulation difficulty in 56% and thrombosis in 10% of cases. 95% procedures involved a combination of angioplasty and coiling with only 5% patients having coiling of ADV alone. Forearm AVFs constituted the majority of the cases as opposed to upper arm AVFs (74% vs. 26% respectively). Primary patency at 3, 6, 12, 18 and 24 months was 90%, 87%, 76%, 70% and 55% respectively. Successful dialysis was achieved in 10 of the 14 fistulae that had hitherto failed to mature. Coil migration was observed in 1 patient, which led to fistula occlusion. Coil embolisation of ADVs is an effective treatment option for dysfunctional fistulae that can be performed at the same time as angioplasty.

Anaesthetic concerns for large intracranial cyst excision: expect the unexpected!

Neurosurgical procedures in infants poses various challenges such as difficulty in venous cannulation, securing invasive vascular lines, difficult airway, controlling intra-cranial tension, managing large fluid shifts to positioning- related issues and temperature maintenance. We hereby present an case of a large intracranial space occupying lesion, suspected to be a hydatid cyst, which later turned out to be an infected ventricular cyst and intraoperative problems. A thorough preparation prior to operation of infected cystic lesion of the brain is required including anticipation of massive blood loss and its management. A slow decompression of the large cystic lesion should be done.

Additional Biliary Cannulation Methods in Patients with Juxtapapillary Duodenal Diverticula

Juxtapapillary diverticula (JPD) can increase the difficulty of biliary cannulation. A number of additional methods have been defined in case of failed cannulation attempt by standard technique. We aimed to investigate the more commonly preferred and practical additional methods among them. A total of 1,205 endoscopic retrograde cholangiopancreatographies (ERCP) performed during a study period of 14 months were prospectively entered into a database. Of these, 222 (18 %) had JPD (123 women, 99 men, mean age 69 years) and 983 had no diverticula (523 women, 460 men, mean age 57 years). Additional cannulation methods used in patients with JPD were recorded. Biliary cannulation time, total procedure time, use of pre-cut papillotomy, and therapeutic success of ERCP were compared between the groups as well. Biliary cannulation was performed by standard technique in 210 patients with JPD (94.5 %). Cannulation was achieved by placement of a guidewire into the pancreatic duct in 6 (2.7 %) and use of two devices in one channel in 2 (0.9 %) patients. There was no significant difference between the total procedure time and therapeutic success of ERCP between the groups. Cannulation time was significantly longer in patients with JPD. Pre-cut papillotomy was performed less in patients with JPD. Presence of JPD does not decrease the therapeutic success of ERCP. Placement of a guidewire in the pancreatic duct or use of two-devices-in-one-channel are practical, successful, safe, and preferred methods which can be used in patients with failed cannulation by standard technique.

A Comparison of Amethocaine and Liposomal Lidocaine Cream as a Pain Reliever Before Venipuncture in Children

Although the use of anesthetic creams before intravenous (IV) insertion has been shown to be both safe and effective in decreasing pain during IV cannulation, the use of any single agent based on efficacy is not yet considered the standard of care in children. We sought to compare a commonly used preparation, 4% liposomal lidocaine (Maxilene), with 4% amethocaine (Ametop), a newer agent with reportedly good efficacy and an intrinsic vasodilatory effect. A total of 60 children aged 5 to 12 years were randomized to receive topically either 4% amethocaine or 4% liposomal lidocaine before IV cannulation. The primary outcome variable was the child's rating of pain using the Faces Pain Scale - Revised. Secondary outcomes included success rate on first IV cannulation attempt, cannulation difficulty ratings by the nurses, and adverse skin reactions. We found no statistically significant differences in self-reported scores in the Faces Pain Scale-Revised with the use of 4% amethocaine versus 4% lidocaine before IV cannulation. There was a trend toward fewer IV cannulation attempts in the 4% amethocaine group. Adverse skin reactions were uncommon, and there were no statistically significant differences between groups. This study demonstrates that there is no difference between 4% amethocaine and 4% liposomal lidocaine in reducing pain associated with IV cannulation in children. Amethocaine confers no advantage in improving IV cannulation success rate over lidocaine. Both agents are associated with few local adverse skin reactions.

Losartan to prevent hyperenzymemia after endoscopic retrograde cholangiopan-creatography: A randomized clinical trial

To study if the angiotensin II receptor blockers (ARB) losartan counteracts pancreatic hyperenzymemia as measured 24 h after endoscopic retrograde cholangiopancreatography (ERCP). A triple-blind and placebo-controlled randomized clinical trial was performed at two Swedish hospitals in 2006-2008. Patients over 18 years of age undergoing ERCP, excluding those with current pancreatitis, current use of ARB, and severe disease, such as sepsis, liver and renal failure. One oral dose of 50 mg losartan or placebo was given one hour before ERCP. The relative risk of hyperenzymemia 24 h after ERCP was estimated using multivariable logistic regression, and expressed as odds ratio with 95% confidence intervals (CIs), including adjustment for potential remaining confounding. Among 76 participating patients, 38 were randomized to the losartan and the placebo group, respectively. The incidence rates of hyperenzymemia and acute pancreatitis among all 76 participating patients were 21% and 12%, respectively. Hyperenzymemia was detected in 9 and 7 patients in the losartan and placebo group, respectively. There were no major differences between the comparison groups regarding cannulation difficulty, findings, or proportion of patients requiring drainage of the bile ducts. There were, however, more pancreatic duct injections, a greater extent of pancreatography, and more biliary sphincterotomies in the losartan group than in the placebo group. Losartan was not associated with risk of hyperenzymemia compared to the placebo group after multi-varible logistic regression analysis (odds ratio 1.6, 95%CI 0.3-7.8). In this randomized trial 50 mg losartan given orally had no prophylactic effect on development of hyperenzymemia after ERCP.

Female gender and post-ERCP pancreatitis: Is the association caused by difficult cannulation?

Objective. Female gender is a well-known risk factor for the development of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, but the underlying mechanism for this increased risk has remained unknown. We hypothesize that cannulation difficulty might play a part in this association. The aim of the current study was to determine whether the female papilla is more difficult to cannulate than the male papilla. Material and methods. Prospective data collection with emphasis on cannulation was conducted in 364 consecutive biliary ERCP procedures performed by very experienced ERCP endoscopists through native papilla in a tertiary referral university hospital. Results. Although the cannulation times seemed to be longer and alternative cannulation techniques seemed to be needed more frequently for successful cannulation in female than male patients, no statistically significant differences (p = 0.061 and 0.054, respectively) in the cannulation process could be found between the genders. Conclusions. The study was not able to confirm that the cannulation of the female papilla is more troublesome than the cannulation of the male papilla.

Predictive factors for difficult intravenous cannulation in pediatric patients at a tertiary pediatric hospital

It is generally believed that certain patient characteristics (e.g., Body Mass Index and age) predict difficulty of intravenous cannulation in children, but there is not much literature evaluating these risk factors. In this study, we investigated predictive factors for success rate at first attempt and time needed for intravenous cannulation. In a prospective cohort study, we observed characteristics of intravenous cannulations in pediatric patients at the operating room (n = 1083) and the outpatient care unit (n = 178) of a tertiary referral pediatric hospital. Time to successful intravenous cannulation, success at first attempt, and potential predictors for difficult cannulation (age, gender, skin color, BMI or weight-to-age z-score, the child being awake or anesthetized, operator profession and surgical specialty) were recorded. Regression models were constructed to find significant predictors. Success at first attempt was 73% and 81%, respectively. In the operating room age, operator and surgical specialty were predictive for a successful first attempt and time to successful cannulation. No significant predictive factors were found for the outpatient care unit. BMI or weight-to-age was not related to difficult intravenous cannulation. This study shows that in one-fifth to one-third of the patients, intravenous cannulation required more than one attempt. It is difficult to predict with accuracy the difficulty of intravenous cannulation solely with easily obtainable patient characteristics.