Cannulation Difficulty Research Articles

Predicting cannulation difficulty in endoscopic retrograde cholangiopancreatography using CT image findings: a decision-tree analysis.

Difficult cannulation during endoscopic retrograde cholangiopancreatography (ERCP) is associated with increased complications; therefore, its prediction is important. To identify radiologic risk factors of difficult cannulation during ERCP based on computed tomography (CT) findings and to develop a predictive model for a difficult cannulation. A total of 171 patients with native papilla who underwent both enhanced CT and ERCP were recruited. Two radiologists independently measured the distal common bile duct (CBD) diameter and choledochoduodenal (CD) angle and analyzed CT images for presence of CBD stone and papilla bulging, size and type of periampullary diverticulum (PAD), and duodenal segment in which major papilla was located. Multivariate logistic regression analysis and decision-tree analysis were performed to identify risk factors for difficult cannulation. Thirty-nine patients underwent a difficult cannulation. The multivariate logistic regression analysis revealed that a smaller CBD diameter, presence of papilla bulging, location of the major papilla other than the descending duodenum, a smaller CD angle, and a higher worrisome PAD score were statistically relevant factors for difficult cannulation (P < 0.049). In the decision-tree analysis, a higher worrisome PAD score was the strongest predictor of difficult cannulation, followed by the presence of papilla bulging, smaller CD angle, and a smaller CBD diameter. The predictive model had an 82.5% overall predictive accuracy. The CT findings-based decision-tree analysis model showed a high accuracy in predicting cannulation difficulty and may be helpful for making pre-ERCP strategy.

Endoscopic Superficialisation of Haemodialysis Arteriovenous Fistulas in Obese Patients – Safety, Feasibility, and Outcomes

The aim was to evaluate the safety and feasibility of endoscopic superficialisation (ES) in patients with deeply located cephalic veins in well matured arteriovenous fistulae (AVF) and to present functional outcomes. All patients with cannulation difficulties due to a deep lying cephalic vein of more than 6mm but with an otherwise matured AVF with a straight needle access segment of at least 6cm were included in this retrospective study. Procedure related safety, defined as completion of ES with no need for conversion to open surgery, and feasibility in terms of cephalic vein depth reduction were assessed. The primary endpoint was three successfully performed haemodialysis sessions using the endoscopically superficialised AVF during a minimum follow up of 12 months. From June 2013 to August 2017, 12 patients with a mean body mass index of 33.5±3.9kg/m2 underwent ES as a second stage procedure following radiocephalic (n=5) or brachiocephalic AVF (n=7) creation. All procedures were conducted endoscopically. Ultrasound imaging 12 weeks post-operatively documented a reduction in the depth of the cephalic vein from a mean of 10.1±1.4 mm to 4.3±0.8 mm. The mean duration of the ES was 69± 26.0min with 67% performed under locoregional anaesthesia. In all but one patient with a cephalic vein of poor wall quality leading to recurrent haematoma, haemodialysis was performed successfully following ES. Endoscopic superficialisation of the cephalic vein is a safe and effective technique. Providing good functional results, ES represents an alternative approach for second stage superficialisation in obese patients.

Cannulation Difficulty During ERCP Varies by Papilla Shape

Over the years, many factors have been evaluated with regard to predicting outcomes of bile duct cannulation during endoscopic retrograde

Complications and pitfalls in minimally invasive atrioventricular valve surgery utilizing endo-aortic balloon occlusion technology

Background: This studyreports the intra-operative complications, reasons for sternotomy conversion(SC) and the important pitfalls associated with minimally invasiveatrioventricular valve surgery by endo-aortic balloon occlusion (MIAS) that mayassist emerging centres in developing safe, efficient and sustainable programs. Methods: Peri-operative data for patientsoperated over the last 5 years was obtained from a prospective database. Intotal, 511 consecutive patients with isolated atrioventricular valve (AVV)disease underwent MIAS (mean age 65.6±13.7 years, 46.8% female, 21.7% redo-cardiacsurgery, 5.7% previous MIAS, 2.9% isolated AVV endocarditis, 13.9% body massindex above 30 kg/m 2 ) at our institution between May 1 st 2013 and April 30 th 2018. The mean EuroSCORE II was 5.9%±9.4% andrheumatic AVV disease was diagnosed in 32 (6.3%) patients. Other surgicalindications included chronic atrial fibrillation (n=142, 27.8%) and leftventricle outflow tract (LVOT) obstruction in conjunction with mitral (MV) ortricuspid valve (TV) disease (n=7, 1.4%). Results: Procedures performed included 122 AVVreplacements (MV =105, TV =17) and 478 AVV repairs (MV=383, TV=95) in isolationor combination. Concomitant procedures included cryo-ablation (n=142, 27.8%)and LVOT resection (n=7, 1.4%). Intra-operative complications that required SCoccurred in 16 (3.1%) patients and in 13 of 399 (3.3%) isolated MV procedures.Reasons for SC included lung adhesions (n=5, 1.0%), cannulation difficulty(n=3, 0.6%), atrioventricular dehiscence (n=1, 0.2%) and bleeding (n=4, 0.8%).Other peri-operative complications included neurological deficit (n=2, 0.4%)and myocardial infarction (n=1, 0.2%). The intra-operative and 30-day mortalityfor the 5-year MIAS series (n=511) was 0.4% (n=2) and 4.5% (n=23) respectively.Complications that resulted in SC (n=16) were associated with a 25% (n=4)30-day mortality. Conclusions: Minimallyinvasive surgical approaches for AVV disease are increasingly being recognizedas the “gold-standard” in the context of rapidly expanding trans-catheter technologyand increasing patient expectations. In an era of strict quality control andclinical governance, emerging MIAS centres need to be aware of the possibleintra-operative complications and potential pitfalls to apply effective riskreduction strategies that encourage safe and sustainable programs.

Safety and Efficacy of ERCP in Patients With Periampullary Diverticulum at a General Hospital in Singapore

Introduction: It has been reported that endoscopic retrograde cholangiopancreatography (ERCP) in the presence of a periampullary diverticulum (PAD) may be associated with more difficulty, morbidity and complications. The safety and efficacy of ERCP in the setting of a periampullary diverticulum in Singapore is not known. The aim of the study is to investigate and compare the success rate, procedure difficulty (ERCP grade, cannulation difficulty, procedure time) and complication rate between patients with and without PAD undergoing ERCP at a single center in Singapore. Methods: This is a retrospective, single center cross-sectional study. A total of 548 ERCP procedures were performed at our endoscopy center from January 2015 to December 2016. Patients with previous ERCP intervention (i.e., sphincterotomy, stent insertion) or an abandoned procedure were excluded. Clinical and endoscopic data were collected from the electronic medical record. A total of 357 procedures in 351 patients were included in the analysis. Results: Of 357 procedures, 116 (32.5%) were found to have PAD. The ampulla was located within the diverticulum in 10 (8.9%), on the edge of the diverticulum in 44 (38.9%), and near the diverticulum in 59 (52.2%) cases. Patients with PAD were significantly older (69 vs. 60 years, p<0.001) and more likely to undergo ERCP for choledocholithiasis as the procedure indication (93.9% vs 83.8%, p<0.007). There was no statistically significant difference in the success and complication rates between the two patient groups. On multivariate logistic regression analysis, younger age was associated with higher cannulation success (p=0.023); older age and indication other than choledocholithiasis were associated with higher cannulation difficulty (p=0.01 and p=0.04 respectively). Patients with PAD were 3.3 times more likely to have common bile duct stones compared to patients without PAD (p=0.006). Conclusion: At a single ERCP center in Singapore, the frequency of PAD in patients undergoing ERCP is 33%. Choledocholithiasis is more prevalent in the PAD group of patients undergoing ERCP. Success and safety of ERCP in patients with and without PAD is comparable. In patients with PAD, older age and procedure indication other than choledocholithiasis are associated with higher ERCP difficulty.

Optimal timing for precutting in cases with difficult biliary cannulation.

Background and study aims In endoscopic retrograde cholangiopancreatography (ERCP), precutting is widely used when achieving biliary cannulation is difficult. However, no consensus has been reached with regard to the best time to initiate precutting. Patients and methods We retrospectively examined 63 patients who underwent precutting for naïve papilla with difficulty in biliary cannulation between 2009 and 2016. The outcomes of the early precut group (≤ 20 min from cannulation until initiating precutting) and the late precut group (> 20 min) were compared. Results Of the 63 patients, 17 (27 %) were in the early precut group and 46 (73 %) were in the late precut group; median time until the initiating precutting was 28 minutes (7 – 50). No significant difference was observed between the two groups in terms of clinical features (age, sex, and indication for ERCP), precutting method, and rate of pancreatic duct stent placement. Significantly higher rates of successful biliary cannulation were observed in the early precut group (16/17; 94 %) than in the late precut group (32/46; 70 %) ( P < 0.05). In 13 patients in whom precutting was commenced after 40 minutes, the rate of successful biliary cannulation was very low at 53 % (7/13). No significant difference was found between the two groups in terms of incidence of complications (pancreatitis in 5 patients and bleeding in 1 patient). Conclusion In actual clinical practice, precutting is commenced approximately 30 minutes after cannulation; however, to successfully achieve biliary cannulation, precutting is recommended to be performed within 20 minutes. Precutting is effective when little inflammation and swelling of the ampulla of Vater is observed. This study was limited in that it was single-center, retrospective and had a small subject sample.

Difficulty in Central Venous Cannulation due to Kinked Guidewire: Intravenous Cannula Comes to Rescue!

Difficulty in Central Venous Cannulation due to Kinked Guidewire: Intravenous Cannula Comes to Rescue!

Patient radiation dose and fluoroscopy time during ERCP: a single-center, retrospective study of influencing factors

Objectives: Recently, both the number and the complexity with associated increased technical difficulty of therapeutic ERCP procedures have significantly increased resulting in longer procedural and fluoroscopy times. During ERCP, the patient is exposed to ionizing radiation and the consequent radiation dose depends on multiple factors. The aim of this study was to identify factors affecting fluoroscopy time and radiation dose in patients undergoing ERCP.Materials and methods: Data related to patient demographics, procedural characteristics and radiation exposure in ERCP procedures (n = 638) performed between August 2013 and August 2015 was retrospectively reviewed and analyzed. Statistically significant factors identified by univariate analyses were included in multivariate analysis with fluoroscopy time (FT) and dose area product (DAP) as dependent variables. Effective dose (ED) was estimated from DAP measurements using conversion coefficient.Results: The factors independently associated with increased DAP during ERCP were age, gender, radiographer, complexity level of ERCP, cannulation difficulty grade, bile duct injury and biliary stent placement. In multivariate analysis the endoscopist, the complexity level of ERCP, cannulation difficulty grade, pancreatic duct leakage, bile duct dilatation and brushing were identified as predictors for a longer FT. The mean DAP, FT, number of acquired images and ED for all ERCP procedures were 2.33 Gy·cm2, 1.84 min, 3 and 0.61 mSv, respectively.Conclusions: Multiple factors had an effect on DAP and FT in ERCP. The awareness of these factors may help to predict possible prolonged procedures causing a higher radiation dose to the patient and thus facilitate the use of appropriate precautions.

Technique to Avoid Hemodialysis Catheter in Patients with Failing Aneurysmal Arteriovenous Fistula by Creating a Concomitant New Arteriovenous Fistula

Autogenous arteriovenous fistula (AVF) is the primary recommended access for hemodialysis. Long-term use will not uncommonly result in AVF aneurysmal degeneration. Aneurysm-associated complications encompass pain, skin ulceration, infection, thrombosis, cannulation difficulties, and life-threatening bleeding. Various methods to repair aneurysmal AVFs have been described. However, there may be circumstances when this is not possible and require insertion of a temporary hemodialysis catheter (HDC) until a new arteriovenous access is created. We describe a case series of creating a new simultaneous AVF while continuing to use the primary failing aneurysmal AVF to avoid placement of an HDC. Once the new AVF becomes operational, the primary aneurysmal AVF can be abandoned. Six patients underwent simultaneous new AVF creation, 4 ipsilateral, and 2 contralateral. None of the patients developed symptomatic steal syndrome or congestive heart failure. Five of 6 patients had successful usage of the new AVF, and subsequently underwent ligation and excision of the aneurysmal AVF, thus avoiding a temporary HDC. Close monitoring for skin compromise and bleeding in the aneurysmal AVF is recommended while the new AVF matures.

Reasons for conversion and adverse intraoperative events in Endoscopic Port Access™ atrioventricular valve surgery and minimally invasive aortic valve surgery.

This study reports the factors that contribute to sternotomy conversions (SCs) and adverse intraoperative events in minimally invasive aortic valve surgery (MI-AVS) and minimally invasive Endoscopic Port Access™ atrioventricular valve surgery (MI-PAS). In total, 3780 consecutive patients with either aortic valve disease or atrioventricular valve disease underwent minimally invasive valve surgery (MIVS) at our institution between 1 February 1997 and 31 March 2016. MI-AVS was performed in 908 patients (mean age 69.2 ± 11.3 years, 45.2% women, 6.2% redo cardiac surgery) and MI-PAS in 2872 patients (mean age 64.1 ± 13.3 years, 46.7% women, 12.2% redo cardiac surgery). A cumulative total of 4415 MIVS procedures (MI-AVS = 908, MI-PAS = 3507) included 1537 valve replacements (MI-AVS = 896, MI-PAS = 641) and 2878 isolated or combined valve repairs (MI-AVS = 12, MI-PAS = 2866). SC was required in 3.0% (n = 114 of 3780) of MIVS patients, which occurred in 3.1% (n = 28 of 908) of MI-AVS patients and 3.0% (n = 86 of 2872) of MI-PAS patients, respectively. Reasons for SC in MI-AVS included inadequate visualization (n = 4, 0.4%) and arterial cannulation difficulty (n = 7, 0.8%). For MI-PAS, SC was required in 54 (2.5%) isolated mitral valve procedures (n = 2183). Factors that contributed to SC in MI-PAS included lung adhesions (n = 35, 1.2%), inadequate visualization (n = 2, 0.1%), ventricular bleeding (n = 3, 0.1%) and atrioventricular dehiscence (n = 5, 0.2%). Neurological deficit occurred in 1 (0.1%) and 3 (3.5%) MI-AVS and MI-PAS conversions, respectively. No operative or 30-day mortalities were observed in MI-AVS conversions (n = 28). The 30-day mortality associated with SC in MI-PAS (n = 86) was 10.5% (n = 9). MIVS is increasingly being recognized as the 'gold-standard' for surgical valve interventions in the context of rapidly expanding catheter-based technology and increasing patient expectations. Surgeons need to be aware of factors that contribute to SC and adverse intraoperative outcomes to ensure that patients enjoy the maximum potential benefit of MIVS and to apply effective risk reduction strategies that encourage safer and sustainable MIVS programmes.

Dorsal metacarpal veins: anatomic variation and potential clinical implications.

The dorsal metacarpal veins are frequently cannulated. Cannulation success is determined by several variable anatomic features. The objective of this study is to classify, for the first time, the anatomic variants of the dorsal metacarpal veins. In this cross-sectional study, 520 university students and staff were conveniently recruited. The dorsal metacarpal veins in 1040 hands were studied. Venous visibility was enhanced by either tourniquet application or near-infrared illumination. Variant patterns of the dorsal metacarpal veins were classified. The final analysis included 726 hands, for an exclusion rate of 30%. Eight pattern types were identified. Three anatomic features informed the variation. Bilateral symmetry of the dorsal metacarpal veins was present in 352 participants (83% of the total). The overall frequency distribution of variants in both hands was similar (P=0.8). The frequency distribution of variants was subject to sexual dimorphism (P=0.001), ethnic variation (P<0.001), and technical variation (P<0.001). The anatomic variants of the dorsal metacarpal veins were sorted into decreasingly frequent primary, secondary, and tertiary groups. The groups may signify a progressive increase in difficulty of peripheral cannulation, in the mentioned order. As such, primary patterns are the most common and likely the easiest to cannulate, while tertiary patterns are the least common and likely the most difficult to cannulate. The preceding premise, in tandem with the bilateral asymmetry of the veins, is clinically significant. With cannulation difficulty likely signifying an underlying tertiary pattern, the contralateral dorsal metacarpal veins are probabilistically characterized by a primary pattern and are, as such, the easier option for peripheral venous cannulation.

PTH-029 Ampullary Characteristics as A Novel Means of Predicting ERCP Complexity

Introduction ERCP is a technically demanding procedure, with significant risk of complications. Cannulation success is widely regarded as a key performance indicator of high- quality ERCP practice (1). Multiple factors affecting the complexity of a complete ERCP procedure have been suggested as a way of adding relevance to success rates and complication incidence. We propose a novel concept where complexity stratification is used to predict outcome based on ampullary characteristics. Methods 200 ERCPs performed on a virgin ampulla were prospectively recorded. We classified ampulla as non-prominent, prominent or distorted by tumour. Cannulation method and number of ampullary contacts were recorded. Cannulation success and incidence of complications were the primary outcome measures. Results The most common indication was biliary duct stones (54%). Ampullae were classified as non-prominent in 107 cases, prominent in 78 and involving tumour in 15. Overall deep cannulation was successful in 189 cases (94%), with significant variation between ampullary groups. Non-prominent and prominent ampullae were more likely to be cannulated successfully, (95.3%, 94.9% respectively), than those involving tumour (80%) (p = 0.004). Fewest contacts prior to cannulation were made on the non-prominent ampullae and most on those involving tumour (p The presence of a peri-ampullary diverticulum or a covering mucosal fold, did not reduce cannulation success. 15 patients had complications (7.5%) - pancreatitis (10), perforation (3), infection (1) and bleeding (1). 12 complications occurred in the non-prominent group, with increased incidence of perforation, pancreatitis and bleeding (p = 0.04). Complications were more likely in younger patients (p = 0.03). Complication rate was not affected by patient gender, cannulation outcome, number of ampullary contacts or trainee involvement. Neither presence of diverticulae nor covering folds increased complication rate. Conclusion The assessment of ampullary characteristics may prove to be a novel means of predicting cannulation difficulty and anticipating risk of complication. Non-prominent ampullae appear to be easier to cannulate, with fewer ampullary contacts and less use of needleknife fistulotomy, but complication rates appear highest. Statistical significance is limited by the sample size and low incidence of cannulation failure and complications, so further study is required. These findings may have implication for case selection in ERCP training, and may add validity to key outcome quality indicators in practice. Reference 1 ASGE. Quality Indicators for ERCP. 2015. Disclosure of Interest None Declared

The efficacy and durability of the Venous Window Needle Guide implanted on uncannulatable arteriovenous fistulas

The Venous Window Needle Guide (VWING; Vital Access Corp, Salt Lake City, Utah) is a surgically implanted titanium device designed to facilitate cannulation of uncannulatable dialysis access arteriovenous fistulas (AVFs) because of excessive depth, aneurysm formation, or tortuosity but that exhibit sufficient flow volume to support hemodialysis. We report the 18-month fistula patency, functionality, and complications of the use of the VWING device. This retrospective study examined AVF patency, VWING functionality, interventions, and device infections at 18months after VWING implantation. The study population comprised the eligible patients enrolled in the VWING Salvage of AV Fistula (SAVE) trial. Fifty-four patients were originally enrolled in the SAVE trial, and 35 were enrolled in the follow-up study. At18months, when considering surgical or percutaneous interventions at the VWING site(s) only, the primary AVF patency rate was 78%. Interventions elsewhere on the AVF, outside the boundaries of the VWING, resulted in a primary patency rate of 38%. The VWING accounted for 13% loss of AVF primary patency compared with 53% loss from the remaining AVFs. The overall AVF assisted primary patency rate was 91%, and the primary patency rate was 21%. VWING secondary functionality, the continued ability to access the fistula through the VWING using a constant site cannulation technique, was 65%. During the 12months after the SAVE Study 80% of patients did not require the use of a central venous catheter. Eleven VWING devices were removed from eight patients, all but one for cannulation difficulties. One device was removed during the SAVE trial because of infection. No device or systemic infection was identified in the ensuing 12months, for an overall systemic infection rate of 0.014 per device-year. An intervention rate of 0.32 per device-year was required to maintain device functionality during the 18-month follow-up period. Implantation of the VWING device is a safe and effective means of establishing hemodialysis access in an otherwise functional but uncannulatable AVF. The device infection rate is acceptably low.

Su1331 Are There Any Useful EUS Findings to Predict Difficulty in ERCP Cannulation?

Su1331 Are There Any Useful EUS Findings to Predict Difficulty in ERCP Cannulation?

Vapocoolants (cold spray) for pain treatment during intravenous cannulation.

Intravenous cannulation is a painful procedure that can provoke anxiety and stress. Injecting local anaesthetic can provide analgesia at the time of cannulation, but it is a painful procedure. Topical anaesthetic creams take between 30 and 90 minutes to produce an effect. A quicker acting analgesic allows more timely investigation and treatment. Vapocoolants have been used in this setting, but studies have reported mixed results. To determine effects of vapocoolants on pain associated with intravenous cannulation in adults and children. To explore variables that might affect the performance of vapocoolants, including time required for application, distance from the skin when applied and time to cannulation. To look at adverse effects associated with the use of vapocoolants. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Latin American Caribbean Health Sciences Literature (LILACS), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Institute for Scientific Information (ISI) Web of Science and the http://clinicaltrials.gov/, http://www.controlled-trials.com/ and http://www.trialscentral.org/ databases to 1 May 2015. We applied no language restrictions. We also scanned the reference lists of included papers. We included all blinded and unblinded randomized controlled trials (RTCs) comparing any vapocoolant with placebo or control to reduce pain during intravenous cannulation in adults and children. Three review authors independently assessed trial quality and extracted data, contacted study authors for additional information and assessed included studies for risk of bias. We collected and analysed data for the primary outcome of pain during cannulation, and for the secondary outcomes of pain associated with application of the vapocoolant, first attempt success rate of intravenous cannulation, adverse events and participant satisfaction. We performed subgroup analyses for the primary outcome to examine differences based on age of participant, type of vapocoolant used, application time of vapocoolant and clinical situation (emergency vs elective). We used random-effects model meta-analysis in RevMan 5.3 and assessed heterogeneity between trial results by examining forest plots and calculating the I(2) statistic. We found nine suitable studies of 1070 participants and included them in the qualitative analyses. We included eight studies of 848 participants in the meta-analysis for the primary outcome (pain during intravenous cannulation). Use of vapocoolants resulted in a reduction in pain scores as measured by a linear 100 mm visual analogue scale (VAS 100) compared with controls (difference between means -12.5 mm, 95% confidence interval (CI) -18.7 to -6.4 mm; moderate-quality evidence). We could not include in the meta-analysis one study, which showed no effects of the intervention.Use of vapocoolants resulted in increased pain scores at the time of application as measured by a VAS 100 compared with controls (difference between means 6.3 mm, 95% CI 2.2 to 10.3 mm; four studies, 461 participants; high-quality evidence) and led to no difference in first attempt success compared with controls (risk ratio (RR) 1.00, 95% CI 0.94 to 1.06; six studies, 812 participants; moderate-quality evidence). We documented eight minor adverse events reported in 279 vapocoolant participants (risk difference (RD) 0.03, 95% CI 0 to 0.05; five studies, 551 participants; low quality-evidence).The overall risk of bias of individual studies ranged from low to high, with high risk of bias for performance and detection bias in four studies. Sensitivity analysis showed that exclusion of studies at high or unclear risk of bias did not materially alter the results of this review. Moderate-quality evidence indicates that use of a vapocoolant immediately before intravenous cannulation reduces pain during the procedure. Use of vapocoolant does not increase the difficulty of cannulation nor cause serious adverse effects but is associated with mild discomfort during application.

Ultrasound-Guided Peripheral Venous Catheterization in Emergency Services

Peripheral venous catheterization is difficult to achieve in some patients, which can delay diagnosis and treatment, causing problems for the patient and frustration for health professionals. 1 Miles G Salcedo A Spear D Implementation of a successful registered nurse peripheral ultrasound-guided intravenous catheter program in an emergency department. J Emerg Nurs. 2012; 38: 353-356 Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Venous catheterization is one of the most frequently used techniques in emergency care settings. Nonetheless, catheter insertion has a 10% to 40% overall failure rate, 2 Leidel BA Kirchhoff C Bogner V et al. Is the intraosseous route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department?. Patient Saf Surg. 2009; 3 (http://www.pssjournal.com/content/3/1/24. Accessed February 3, 2016): 24 Crossref PubMed Google Scholar and although attempts have been made to define the patient characteristics that contribute to the difficulty of cannulation, 3 Lapostolle F Catineau J Garrigue B et al. Prospective evaluation of peripheral venous access difficulty in emergency care. Intensive Care Med. 2007; 33: 1452-1457 Crossref PubMed Scopus (118) Google Scholar the only relationship that has been established is between certain disease conditions and the difficulty of intravenous (IV) access. Patients with diabetes or heart conditions have more fragile veins, 4 Walsh G Difficult peripheral venous access: recognizing and managing the patient at risk. J Assoc Vasc Access. 2008; 13: 198-203 Abstract Full Text Full Text PDF Scopus (39) Google Scholar and the patient’s clinical status, pain level, or state of anxiety can affect the difficulty of implementing this technique. 5 Yen K Riegert A Gorelick MH Derivation of the DIVA score: a clinical prediction rule for the identification of children with difficult intravenous access. Pediatr Emerg Care. 2008; 24: 143-147 Crossref PubMed Scopus (140) Google Scholar Other characteristics that affect IV catheterization in the general population are obesity or being underweight 6 Sebbane M Claret PG Lefebvre S et al. Predicting peripheral venous access difficulty in the emergency department using body mass index and a clinical evaluation of venous accessibility. J Emerg Med. 2013; 44: 299-305 Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar and repeated venous administration of prescription drugs. 7 Fields JM Dean AJ Todman RW et al. The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity. Am J Emerg Med. 2012; 30: 1134-1140 Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar Studies analyzing the ultrasound-guided catheterization technique have shown that a high percentage of the patients for whom this technique has been used have chronic diseases 8 Schoenfeld E Boniface K Shokoohi H ED technicians can successfully place ultrasound-guided intravenous catheters in patients with poor vascular access. Am J Emerg Med. 2011; 29: 496-501 Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar or high body mass index. 9 Elia F Ferrari G Molino P et al. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. Am J Emerg Med. 2012; 30: 712-716 Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar Laia Salleras-Duran is Registered Nurse, Emergency Department, Hospital of Figueres, Fundació Salut Empordà, Girona, Spain. Concepció Fuentes-Pumarola is Professor, Nursing Department, University of Girona, Girona, Spain. Núria Bosch-Borràs is Registered Nurse, Hospital of Figueres, Fundació Salut Empordà, Girona, Spain. Xavier Punset-Font is Registered Nurse, Hospital of Figueres, Fundació Salut Empordà, Girona, Spain. Francesc-Xavier Sampol-Granes is Registered Nurse, Hospital of Figueres, Fundació Salut Empordà, Girona, Spain.

Pancreatic Stenting Reduces Post-ERCP Pancreatitis and Biliary Sepsis in High-Risk Patients: A Randomized, Controlled Study.

Background. Endoscopic retrograde cholangiopancreatography (ERCP) is an established treatment modality for bile duct disorders, but patients have a risk of post-ERCP pancreatitis (PEP) and biliary sepsis. Aim. To evaluate the effectiveness and safety of pancreatic stent for prophylaxis of PEP and biliary sepsis in high-risk patients with complicating common bile duct (CBD) disorders. Methods. Two hundred and six patients with complicating confirmed or suspected CBD disorders were randomly assigned to receive ERCP with pancreatic stenting (experimental group) or without stenting (control group). Primary outcome measure was frequency of PEP, and secondary outcome measures included operative time, blood loss, postoperative recovery times, and other ERCP-associated morbidities. Results. Baseline age, sex, CBD etiology, concomitant medical/surgical conditions, cannulation difficulty, and ERCP success were comparable between the two groups (all P > 0.05). Compared to the control group, the experimental group had a significantly lower frequency of PEP (7.7% versus 17.7%, P < 0.05) and positive bile microbial culture (40.4% versus 62.7%, P < 0.05). However, the two groups were similar in operative time, blood loss, postoperative recovery times, and other ERCP-associated morbidities (all P > 0.05). Conclusions. Pancreatic stenting can reduce the occurrence of PEP and biliary sepsis in high-risk patients with complicating CBD disorders but does not increase other ERCP-associated morbidities. This trial is registered with the Chinese Clinical Trial Registry (registration identifier ChiCTR-OCH-14005134).

Nafamostat Mesilate for Prevention of Post-ERCP Pancreatitis

We aimed to evaluate the efficacy of nafamostat on the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Medline, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were searched until April 18, 2014. Seven randomized controlled trials and 2956 patients met the search criteria. When compared with nonnafamostat, the incidence of PEP was reduced to 53% in the patients who received nafamostat (risk ratio [RR], 0.47; 95% confidence interval [CI], 0.34-0.63). Further analyses were conducted based on the different risk classifications (n = 641 in patients with high risks: RR, 0.54; 95% CI, 0.30-0.96 and n = 944 with low risks: RR, 0.31; 95% CI, 0.17-0.56), PEP severities (n = 1654: RR, 0.38; 95% CI, 0.25-0.59 for mild; RR, 0.37; 95% CI, 0.15-0.96 for moderate; RR, 0.92; 95% CI, 0.13-6.38 for severe), and nafamostat doses (n = 1902: RR, 0.42; 95% CI, 0.28-0.63 for 20 mg; n = 1150: RR, 0.40; 95% CI, 0.25-0.63 for 50 mg). However, there was no reduction of the incidence of post-ERCP hyperamylasemia (n = 1585; 95% CI, 0.68-1.45) or cannulation difficulty (n = 1585; 95% CI, 0.91-1.23). Pooled analyses from current randomized controlled trials support the effectiveness of nafamostat for prophylaxis of PEP.

膵管プレカット法が有効であった選択的膵管挿入に難渋した膵石症の1例

症例はアルコール性慢性膵炎症例の53歳の女性である．膵頭部主膵管内の膵石による腹痛発作のため，ESWLを施行したが，破砕困難なためERCPによる膵石除去を試みた．主膵管末端部の狭窄と屈曲により選択的膵管挿入が困難なため，先端長0mmの通常型パピロトームを用いて膵管プレカットを行い，深部挿入に成功した．バスケットカテーテルで膵石摘出を試みたが，把持できないため膵管ステントを挿入して一旦終了した．膵管プレカット後，軽症膵炎が発症したが，保存的治療により治癒し，5日後に再度ERCPを施行した．膵管ステントを抜去し，バスケットカテーテルで膵石除去に成功した．その後は外来で約半年間経過観察中であるが，自覚症状は認めていない．選択的膵管挿入が困難な症例をときに経験するが，その対処法に関する報告は少なく，対処法のひとつとして膵管プレカット法が有用な方法であることが示唆された．

Use of the Amplatzer Type 2 Plug for Flow Redirection in Failing Autogenous Hemodialysis Fistulae.

To present our experience with redirecting the outflow of mature arteriovenous fistulae (AVFs) in patients with cannulation and/or suboptimal flow problems by percutaneous intervention using the Amplatzer Vascular Plug II (AVP II). We retrospectively reviewed patients who presented with difficulty in cannulation and/or suboptimal flow in the puncture zone of the AVF and who underwent intervention using the AVP II to redirect the outflow through a better cannulation zone from March 2009 to November 2012. The mean survival rate of all AVFs was estimated, and the effects of patient age, sex, and AVF age on the AVF survival time were determined. In total, 31 patients (17 male and 14 female) with a mean age of 57.8 years (range, 20-79 years) were included. In 2 patients, the AVF failed within the first 15 days because of rapid thrombosis. In 9 patients, the new AVF route was working effectively until unsalvageable thrombosis developed. One of the 31 patients died 9 months before the last radiologic evaluation. The new AVF route was still being used for dialysis in the remaining 19 patients. The mean AVF survival rate was 1,061.4 ± 139.4 days (range, 788-1,334 days). Patient age, sex, and AVF age did not affect the survival time. We suggest that the AVP II is useful for redirecting the outflow of AVFs with cannulation problems and suboptimal flow. Patency of existing AVFs may be extended, thereby extending surgery-free or catheter intervention-free survival period.