Jugular Site Research Articles

Central Line-associated Bloodstream Infections: CLABSI Care Bundle Approach of Prevention

Infections of the bloodstream that is caused by vascular catheters can be divided into two primary groups both bloodstream infections that can be traced back to catheters and those that can be traced back to central lines. There are clear differences between the two, despite the fact that they are interchangeable. Infections that cannot be traced to an infection unrelated to a catheter but still arise when a central venous catheter is present or within 48 h after the catheter has been withdrawn are referred to as having a “central line-associated bloodstream infection” (CLABSI). A “bundle” of catheter care refers to the provision of care utilizing a consistent combination of actions to reduce the risk of bloodstream infections associated with central lines CLABSIs. Hand hygiene, the use of maximum sterile barriers during line insertion, the washing of the insertion site with chlorhexidine, avoiding the use of the femoral and jugular sites for line insertion, and the timely removal of superfluous catheters are all components of this combination. The implementation of an evidence-based CLABSI prevention bundle and process monitoring by direct observation led to a considerable improvement in reducing the CLABSI rate in adult intensive care unit patients, which was then maintained over time.

Therapeutic Effect of Equine Musculoskeletal Disease using Autogenous Platelet Rich Plasma

This study evaluated the therapeutic effect using autogenous platelet-rich plasma (PRP) for the musculoskeletal disease of Thoroughbred horses raised in South Korea. Twenty-five Thoroughbred horses (15 adult horses more than 2 years old, 10 fostering horses less than 2 years old) were diagnosed with musculoskeletal disorders (2 horses with desmitis of the suspensory ligament, 9 horses with osteoarthritis, 14 horses with fracture) by ultrasound and X-ray were used in this study. We collected venous blood of patients by using ACP Double Syringe after sterilization of jugular site, and then autogenous PRP was taken through centrifugation. We were observed the healing process of the lesion by using ultrasonography and X-ray images after injecting 4mL of autogenous PRP into each lesion for 2-times. Results of this study, 20 (80%) of 25 damaged horses returned to normal competition. The core lesion in the ligament disappeared in 90 days and healthy tissue regenerated. The fracture line of the cortex of bone disappeared in 60 days, and no side effects such as osteophytosis during healing progress. Remodeled articular surface, and cartilage defect, a fragment in joint disappeared. It could be confirmed that applying autogenous PRP treatment is an excellent regenerative therapy for equine locomotorium lesions.

Abstract 231: Patient, Operator, And Procedural Characteristics Of Guidewire Retention As A Complication Of Vascular Catheter Insertion

Introduction: Guidewire retention after intravascular catheter insertion is considered a “never event.” Prior reports attribute this complication to various characteristics including uncooperative patients, operator inexperience, off-hour or emergent insertion, and underutilization of ultrasound guidance. In this descriptive analysis of consecutive events, we assessed the frequency of patient, operator, and procedural factors in guidewire retention. Methods: All consecutive incidents of guidewire retention across 10 hospitals within the Cleveland Clinic Health System in Ohio from August 2007 to October 2015 were prospectively identified and retrospectively analyzed. Data were manually obtained from the electronic medical records and reviewed for potential contributing factors for guidewire retention including patient, operator, and procedural characteristics. Results: A total of 24 guidewire retention events were identified. Overall, the median age was 74 years, 58% were males, and the median body mass index was 26.5 kg/m 2 . A total of 12 (50%) individuals were sedated during the procedure. Most incidents (10 [42%]) occurred in internal jugular venous access sites. The majority of cases (13 [54%]) were performed or supervised by an attending. Among all cases, 3 (12%) were performed by first-year trainees, 7 (29%) by residents, 3 (12%) by fellows, and 4 (17%) by certified nurse practitioners. Overall, 16 (67%) events occurred during regular working hours (8AM - 5PM). In total, 22 (92%) guidewires were inserted non-emergently, with 2 (8%) during a cardiac arrest. Ultrasound guidance was used in all but 1 case. Conclusion: Guidewire retention can occur even in the presence of optimal patient, operator, and procedural circumstances, highlighting the need for constant awareness of this risk. Efforts to eliminate this important complication will require attention to issues surrounding the technical performance of the procedure.

Comparison of Central Venous Catheter Related Deep Venous Thrombosis According to Insertion Site in an Intensive Care Unit of Bangladesh

Background: Central venous catheter (CVC) is usually inserted into subclavian, internal jugular, orfemoral vein in critically ill patients. CVCs are associated with intravascular (infectious, thrombotic) andmechanical complications. CVC related deep venous thrombosis (DVT) is a common intravascularcomplication.Objectives: To see the variation in occurrence of CVC related deep venous thrombosis according todifferent insertion site. Method: It was a prospective observational study conducted in dept. of Critical Care Medicine, BIRDEMGeneral Hospital; during a period of May, 2016 to July, 2019. Purposive sampling was conducted in patientsfulfilling the selection criteria. The CVCs were percutaneously inserted using the Seldinger techniquewith standard operating procedure. After CVC insertion, patients were followed up daily to see any signof deep venous thrombosis. After catheter removal [due to any cause including suspected catheterrelated blood stream infection (CRBSI), DVT, mechanical cause], all the study patients were investigated byduplex ultrasonography (USG) within 2 days for detection of venous thrombosis. The outcome wascatheter related deep venous thrombosis (DVT). Results: A total 349 patients, of which 167 (47.9%) patients had CVC in subclavian, 88 (25.2%) in internaljugular and 94 (26.9%) in femoral vein. Total 12 patients were suspected to have catheter related DVT, but11(3.2%) patients were confirmed as DVT by duplex USG. DVT occurred significantly higher in femoralcatheter site (8.5%) than subclavian (1.8%) and internal jugular site (0%). Conclusion: The occurrence of catheter related DVT was higher in femoral site than other two sites. J MEDICINE 2022; 23: 20-23

Vascular access for renal replacement therapy among 459 critically ill patients: a pragmatic analysis of the randomized AKIKI trial

BackgroundVascular access for renal replacement therapy (RRT) is routine question in the intensive care unit. Randomized trials comparing jugular and femoral sites have shown similar rate of nosocomial events and catheter dysfunction. However, recent prospective observational data on RRT catheters use are scarce. We aimed to assess the site of RRT catheter, the reasons for catheter replacement, and the complications according to site in a large population of critically ill patients with acute kidney injury.Patients and methodsWe performed an ancillary study of the AKIKI study, a pragmatic randomized controlled trial, in which patients with severe acute kidney injury (KDIGO 3 classification) with invasive mechanical ventilation, catecholamine infusion or both were randomly assigned to either an early or a delayed RRT initiation strategy. The present study involved all patients who underwent at least one RRT session. Number of RRT catheters, insertion sites, factors potentially associated with the choice of insertion site, duration of catheter use, reason for catheter replacement, and complications were prospectively collected.ResultsAmong the 619 patients included in AKIKI, 462 received RRT and 459 were finally included, with 598 RRT catheters. Femoral site was chosen preferentially (n = 319, 53%), followed by jugular (n = 256, 43%) and subclavian (n = 23, 4%). In multivariate analysis, continuous RRT modality was significantly associated with femoral site (OR = 2.33 (95% CI (1.34–4.07), p = 0.003) and higher weight with jugular site [88.9 vs 83.2 kg, OR = 0.99 (95% CI 0.98–1.00), p = 0.03]. Investigator site was also significantly associated with the choice of insertion site (p = 0.03). Cumulative incidence of catheter replacement did not differ between jugular and femoral site [sHR 0.90 (95% CI 0.64—1.25), p = 0.67]. Catheter dysfunction was the main reason for replacement (n = 47), followed by suspected infection (n = 29) which was actually seldom proven (n = 4). No mechanical complication (pneumothorax or hemothorax) occurred.ConclusionFemoral site was preferentially used in this prospective study of RRT catheters in 31 French intensive care units. The choice of insertion site depended on investigating center habits, weight, RRT modality. A high incidence of catheter infection suspicion led to undue replacement.

Comparison of mechanical complications of central venous catheter according to the insertion site in an intensive care unit of Bangladesh

Background: Central venous catheter (CVC) insertion is very common in intensive care unit (ICU). CVC is usually inserted in subclavian, internal jugular and femoral veins. However, CVC insertion may lead to significant mechanical complications. Our aim was to detect the occurrence of CVC related mechanical complications according to different insertion site.
 Methods: This prospective observational study was carried out during the period of May 2016 to July 2019 in Department of Critical Care Medicine, BIRDEM General Hospital, Dhaka, enrolling 349 adult patients requiring new CVC insertion in ICU.
 Results: Among 349 study subjects, 167 CVC were inserted through subclavian vein, 88 through internal jugular and 94 through femoral vein. There was no significant difference among three groups (subclavian / internal jugular / femoral) in terms of age, gender distribution, presence of co-morbid illness.Total mechanical complicationsin study population was 43 (12.3 %) including pneumothorax (14, 4.0%), arterial puncture (10, 2.9%), hemorrhage (11, 3.2%), catheter tip malposition (6, 1.7%), hemothorax (1, 0.3%) and lost guidewire (1, 0.3%). Pneumothorax was more with internal jugular (9.1%) than subclavian (3.6 %) route, which was statistically significant (p=0.007). Although hemorrhage and arterial puncture events were higher with femoral site than subclavian or internal jugular, which were not significant. Catheter tip malposition occurred in 4 (2.4%) patients with subclavian insertion and 2 (2.3%) patients with internal jugular site, no such event in femoral site. Hemothorax and lost guidewire occurred in only 1 patient with subclavian and internal jugular site respectively. Site-wise total mechanical complications were higher in internal jugular (17.0%) followed bysubclavian (10.8%) site and femoral site (10.6%).
 Conclusion: In this study, though not statistically significant, CVC related mechanical complications occurred more in subclavian site than in internal jugular or femoral insertion site.
 Birdem Med J 2020; 10(2): 115-119

AIUM Practice Parameter for the Use of Ultrasound to Guide Vascular Access Procedures.

AIUM Practice Parameter for the Use of Ultrasound to Guide Vascular Access Procedures.

Jugular vs femoral vein for central venous catheterization in pediatric cardiac surgery (PRECiSE): study protocol for a randomized controlled trial

BackgroundPlacement of central venous catheters (CVCs) is essential and routine practice in the management of children with congenital heart disease. The purpose of the present protocol is to evaluate the risk for infectious complications in terms of catheter colonization, catheter line–associated bloodstream infections, and catheter-related bloodstream infections (CRBSIs), and the mechanical complications from different central venous access sites in infants and newborns undergoing cardiac surgery.MethodsOne hundred sixty patients under 1 year of age and scheduled for cardiac surgery will be included in this randomized controlled trial (RCT); patients will be randomly allocated to the jugular or femoral vein arms. CVC insertion will be performed by one of three selected expert operators.DiscussionThe choice of the insertion site for central venous catheterization can influence the incidence and type of infectious complications in adults but this is not unanimously evidenced in the pediatric setting. The experimental hypothesis of this RCT is that the jugular insertion site is less likely to induce catheter colonization and CRBSI than the femoral site.Trial registrationClinicalTrials.gov Identifier: NCT03282292. Registered on 12 September 2017.

The Effect of Nurses’ Implementation of Central Vascular Catheter Maintenance Care Bundle on Bloodstream Infection Among ICU Patients in KFGH and KAAUH

Background: Bloodstream infections (BSIs) are the most common type of healthcare-associated infections in clinical settings. Bloodstream infections are a leading known cause to increase the risk of patients' morbidity, mortality and length of hospital stay, and additionally, are typically increased in patients with severe underlying diseases.. The study of CVC bundle implementation has not been adequately explored in Saudi Arabia (SA). This study aimed to assess the effect of nurses' implementation of central vascular catheter maintenance care bundle on blood stream infection among intensive care unit patients at King Fahd General Hospital (KFGH) and King Abdul-Aziz University Hospital (KAAUH). Objectives: Assess the effect of nurses' implementation of central vascular catheter maintenance care bundle on blood stream infection. Methods: This study used quantitative research as a cause of defining the relationships between the variables which are the nurses’ implementation of the central vascular catheter maintenance care bundle and the bloodstream infection rate. An observational study were as it enables the researcher to focus on specific behaviours. The tools used in this study were Central vascular catheter maintenance care bundle checklist was used to assess the effect of nurses' implementation of a central vascular catheter maintenance care bundle on blood stream infection. A convenience sample of 63 patients of both sexes with central vascular catheter was selected from the two institutions. Ethical approval was granted from KAUH and KFHJ. Data collection was conducted for six months. Results: A total of 63 patients and 37 nurses participated in this study. The average age of the study population was 51 years old (SD score of 51±20 years). The majority of gender were male (65% )of the admitted patients were male (78%) had poor knowledge scores about contraception before counseling. The study reveals that the majority had diploma level education (87%) while(13%) had a bachelor's degree. As the researcher observed the nurses implementation of central vascular catheter maintenance care bundle, the table revealed that there was statistically significant difference between nurses' performing hand washing in relation to patients' bloodstream infection (P-value=0.001). There were (53.9%) of the nurses at both hospitals didn't perform hand washing techniques which lead to exposure of patients to infection. Other influencing factors included misapplication of chlorhexidine antiseptic at KFGH which increased exposure to infection and showed significant statistical difference (P-value = 0.000). The fourth element of proper central vascular catheter site selection indicated the elevation of infection at the jugular vein site in (36.5%) of the cases followed by the femoral site (19%) it was not found at the subclavian vein site as recommended in current evidence. In addition, it was also noted that there was no significant correlation between exposure to infection and the daily review of central vascular catheter necessity Conclusions and recommendations: The relationship between nurses' implementation of central vascular catheter maintenance care bundle and bloodstream infection has had a positive effect on patients' bloodstream infection rates of intensive care unit As a result, this study recommends sustained efforts to educate the healthcare workers regarding the importance of bundle implementation and central vascular catheter care and provision of prompt feedback on adherence to aseptic technique. Moreover, healthcare providers should be involved in educational sessions on central line insertion, handling and maintenance.

Radiation-induced Changes in the Electrophoretic Profile of Serum Albumin

ABSTRACT Albumin protein profiles were investigated in electrophoresis system in relation to the whole body exposition to the radiation. Two groups of rats Wistar were set up as the control (CG) and the irradiated one (IG). The IG was exposed to Co-60 at a dose of 5 Gy. After a 72-hour exposition, 300 μL of blood was collected in the inferior vena cava, renal, jugular, hepatic, and pulmonary veins and the serum separated. The albumin protein was identified by vertical electrophoresis in acrylamide Commassi blue or silver stained. The calibration procedure was applied to albumin samples with well-known concentrations. The mathematical correlation was developed involving electrophoretic parameters of band intensities and sizes from gel representation, providing values of protein concentrations in comparison with standard bands with known concentrations. There were significant differences in the physiological concentrations in the jugular and pulmonary sites in relation to renal and cava regional sites. Significant differences induced by radiation in serum albumin concentration were also found in hepatic and jugular sites. Alteration of albumin concentration was found as a nearly effect from whole body irradiation. This phenomenon points out to alterations in cell metabolism in the liver justified by a possible indication of proteomics damage from radiation.

Incidence of central venous catheter hub contamination

PurposeTo investigate microorganisms causing central venous catheter contamination and how this contamination differs across different catheter metrics. Materials and methodsAfter obtaining IRB approval and informed consent, 830 cultures were prospectively obtained from 45 ICU patients with central venous catheter or peripherally inserted central catheter. Bacterial colonies were identified by mass spectrometry. ResultsBacterial contamination of central catheter hubs occurred 44% of the time in this study in the ICU setting. Coagulase-positive staphylococci cultures had higher median (±interquartile range) CFUs (12±232) versus coagulase-negative (3±10) and other bacteria (1±3; P<0.001). Bacterial contamination was associated with various metrics. Higher incidence (P<0.05) of coagulase-positive staphylococci cultures was associated with hub-only connections (a “hub” being a female connection; 10.9% vs. 7.9% male connections), connections without a manifold (1lumen device that mixes multiple infusions together; 9.7% vs. 0% with manifold); and central venous pressure monitoring connections (25.8% vs. 7.1% without). Internal jugular sites (10.0% vs. 2.7% femoral, 6.2% PICC, P=0.031) and medial lumens of triple lumen catheters (11.9% vs. 5.6% distal, 7.0% proximal, P=0.049) had increased incidence of higher bacteria loads (>15 CFUs). ConclusionsThis study found a high incidence of central access catheter hub bacterial contamination, which correlated with positive blood cultures in 2 of 3 total bacteremia cases identified in the 45 patients.

The Effect of Nurses' Implementation of Central Vascular Catheter Maintenance Care Bundle on Bloodstream Infection among ICU Patients in KFGH and KAAUH

Background:Bloodstream infections (BSIs) are the most common type of healthcare-associated infections in clinical settings. Bloodstream infections are a leading known cause to increase the risk of patients' morbidity, mortality and length of hospital stay, and additionally, are typically increased in patients with severe underlying diseases.. The study of CVC bundle implementation has not been adequately explored in Saudi Arabia (SA). This study aimed to assess the effect of nurses' implementation of central vascular catheter maintenance care bundle on blood stream infection among intensive care unit patients at King Fahd General Hospital (KFGH) and King Abdul-Aziz University Hospital (KAAUH). Objectives:Assess the effect of nurses' implementation of central vascular catheter maintenance care bundle on blood stream infection. Methods: This study used quantitative research as a cause of defining the relationships between the variables which are the nurses’ implementation of the central vascular catheter maintenance care bundle and the bloodstream infection rate. An observational study were as it enables the researcher to focus on specific behaviours. The tools used in this study were Central vascular catheter maintenance care bundle checklist was used to assess the effect of nurses' implementation of a central vascular catheter maintenance care bundle on blood stream infection. A convenience sample of 63 patients of both sexes with central vascular catheter was selected from the two institutions. Ethical approval was granted from KAUH and KFGH. Data collection was conducted for six months. Results: A total of 63 patients and 37 nurses participated in this study. The average age of the study population was 51 years old (SD score of 51±20 years). The majority of gender were male (65% )of the admitted patients were male (78%) had poor knowledge scores about contraception before counseling. The study reveals that the majority had diploma level education (87%) while(13%) had a bachelor's degree. As the researcher observed the nurses implementation of central vascular catheter maintenance care bundle, the table revealed that there was statistically significant difference between nurses' performing hand washing in relation to patients' bloodstream infection (P-value=0.001). There were (53.9%) of the nurses at both hospitals didn't perform hand washing techniques which lead to exposure of patients to infection. Other influencing factors included misapplication of chlorhexidine antiseptic at KFGH which increased exposure to infection and showed significant statistical difference (P-value = 0.000). The fourth element of proper central vascular catheter site selection indicated the elevation of infection at the jugular vein site in (36.5%) of the cases followed by the femoral site (19%) it was not found at the subclavian vein site as recommended in current evidence. In addition, it was also noted that there was no significant correlation between exposure to infection and the daily review of central vascular catheter necessity Conclusions and Recommendations: The relationship between nurses' implementation of central vascular catheter maintenance care bundle and bloodstream infection has had a positive effect on patients' bloodstream infection rates of intensive care unit As a result, this study recommends sustained efforts to educate the healthcare workers regarding the importance of bundle implementation and central vascular catheter care and provision of prompt feedback on adherence to aseptic technique. Moreover, healthcare providers should be involved in educational sessions on central line insertion, handling and maintenance.

Guidewire exchange vs new site placement for temporary dialysis catheter insertion in ICU patients: is there a greater risk of colonization or dysfunction?

BackgroundIntensive care unit (ICU) patients require dialysis catheters (DCs) for renal replacement therapy (RRT). They carry a high risk of developing end-stage renal disease, and therefore their vascular access must be preserved. Guidewire exchange (GWE) is often used to avoid venipuncture insertion (VPI) at a new site. However, the impact of GWE on infection and dysfunction of DCs in the ICU is unknown. Our aim was to compare the effect of GWE and VPI on DC colonization and dysfunction in ICU patients.MethodsUsing data from the ELVIS randomized controlled trial (RCT) (1496 ICU adults requiring DC for RRT or plasma exchange) we performed a matched-cohort analysis. Cases were DCs inserted by GWE (n = 178). They were matched with DCs inserted by VPI. Matching criteria were participating centre, simplified acute physiology score (SAPS) II +/-10, insertion site (jugular or femoral), side for jugular site, and length of ICU stay before DC placement. We used a marginal Cox model to estimate the effect of DC insertion (GWE vs. VPI) on DC colonization and dysfunction.ResultsDC colonization rate was not different between GWE-DCs and VPI-DCs (10 (5.6 %) for both groups) but DC dysfunction was more frequent with GWE-DCs (67 (37.6 %) vs. 28 (15.7 %); hazard ratio (HR), 3.67 (2.07–6.49); p < 0.01). Results were similar if analysis was restricted to DCs changed for dysfunction.ConclusionsGWE for DCs in ICU patients, compared with VPI did not contribute to DC colonization or infection but was associated with more than twofold increase in DC dysfunction.Trial registrationThis study is registered with ClinicalTrials.gov, number NCT00563342. Registered 2 April 2009.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1402-6) contains supplementary material, which is available to authorized users.

Blood mixtures: impact of puncture site on blood parameters.

Various puncture routes, veins, arteries, heart, are used to take blood in animals. For anatomical reasons, differences in blood composition are expected among puncture sites. However, this issue has been rarely assessed and contrasted results have been reported: strong effects of puncture site versus a lack of effect. We captured free-ranging freshwater turtles from different locations to compare the mean concentrations of 12 blood parameters (metabolites, hormone, ions, and enzyme) among three puncture sites: (1) a lateral branch of the jugular vein, (2) a dorsal subcarapacial cervical plexus (sometimes incorrectly referred as the 'cervical sinus' in the literature), and (3) a caudal plexus site (sometimes incorrectly referred as the 'caudal sinus'). Because we used very small syringes (27-30G), we were able to separate lymph, blood, or blood-lymph mixtures. Our results show very strong effects of puncture site and of mixture level (mean maximal difference between sites was 250%). We also found strong sex and geographical effects. Typically, there were differences in concentrations of blood solutes sampled from the lateral jugular vein and subcarapacial plexus, mainly due to sampling a mixture of blood and lymph from the 'blood' at the subcarapacial site and pure blood from the lateral jugular site, and likewise, samples from the caudal site were highly variable due to often sampling a mixture of blood and lymph. These results have technical and fundamental implications, especially when performing comparative analyses. Further, by selecting precise puncture sites, physiological differences between lymph and blood compartments could be investigated.

We still go for the jugular: implications of the 3SITES central venous catheter study for nephrology

The 3SITES study randomly assigned a nontunneled central venous catheter site in over 3000 adults treated in intensive care units. The subclavian site was associated with a lower rate of short-term complications, including catheter-related bloodstream infection and deep venous thrombosis, compared to the femoral or internal jugular site. Nephrologists should be aware of this study and should continue to advocate for alternatives to subclavian vein catheter placement in patients with chronic kidney disease who are expected to require arteriovenous access for dialysis in the future.

Is long-axis view superior to short-axis view in ultrasound-guided central venous catheterization?

To evaluate whether using long-axis or short-axis view during ultrasound-guided internal jugular and subclavian central venous catheterization results in fewer skin breaks, decreased time to cannulation, and fewer posterior wall penetrations. Prospective, randomized crossover study. Urban emergency department with approximate annual census of 60,000. Emergency medicine resident physicians at the Denver Health Residency in Emergency Medicine, a postgraduate year 1-4 training program. Resident physicians blinded to the study hypothesis used ultrasound guidance to cannulate the internal jugular and subclavian of a human torso mannequin using the long-axis and short-axis views at each site. An ultrasound fellow recorded skin breaks, redirections, and time to cannulation. An experienced ultrasound fellow or attending used a convex 8-4 MHz transducer during cannulation to monitor the needle path and determine posterior wall penetration. Generalized linear mixed models with a random subject effect were used to compare time to cannulation, number of skin breaks and redirections, and posterior wall penetration of the long axis and short axis at each cannulation site. Twenty-eight resident physicians participated: eight postgraduate year 1, eight postgraduate year 2, five postgraduate year 3, and seven postgraduate year 4. The median (interquartile range) number of total internal jugular central venous catheters placed was 27 (interquartile range, 9-42) and subclavian was six catheters (interquartile range, 2-20). The median number of previous ultrasound-guided internal jugular catheters was 25 (interquartile range, 9-40), and ultrasound-guided subclavian catheters were three (interquartile range, 0-5). The long-axis view was associated with a significant decrease in the number of redirections at the internal jugular and subclavian sites, relative risk 0.4 (95% CI, 0.2-0.9) and relative risk 0.5 (95% CI, 0.3-0.7), respectively. There was no significant difference in the number of skin breaks between the long axis and short axis at the subclavian and internal jugular sites. The long-axis view for subclavian was associated with decreased time to cannulation; there was no significant difference in time between the short-axis and long-axis views at the internal jugular site. The prevalence of posterior wall penetration was internal jugular short axis 25%, internal jugular long axis 21%, subclavian short axis 64%, and subclavian long axis 39%. The odds of posterior wall penetration were significantly less in the subclavian long axis (odds ratio, 0.3; 95% CI, 0.1-0.9). The long-axis view for the internal jugular was more efficient than the short-axis view with fewer redirections. The long-axis view for subclavian central venous catheterization was also more efficient with decreased time to cannulation and fewer redirections. The long-axis approach to subclavian central venous catheterization is also associated with fewer posterior wall penetrations. Using the long-axis view for subclavian central venous catheterization and avoiding posterior wall penetrations may result in fewer central venous catheter-related complications.

Accidental placement of central venous catheter tip into internal mammary vein.

Sir, Central venous catheter (CVC) plays an important role in the management of critically ill patients in terms of central venous pressure (CVP) monitoring, administration of vasopressors, inotropes, blood products, and parenteral nutrition. The ultrasound guided central venous cannulation has become a routine practice in recent years due to its lower complication rates and lesser errors during insertion. The ultrasound-guided catheter insertion does not prevent or help in the detection of misplaced catheter tips. We present a case of a 25-year-old male, known case of fungal sinusitis and mycotic aneurysm of right internal carotid artery admitted to our tertiary care Intensive Care Unit following surgery (craniotomy) at an outside hospital. He was shifted for evaluation and management of shortness of breath and sepsis. It was decided to remove his old left subclavian central line in view of sepsis and replace it with a new left internal jugular vein (IJV) cannulation with the help of ultrasound guidance. Left internal jugular site was selected as all other sites were cannulated previously. The CVC on chest X-ray looked as if the catheter was entering the left atrium [Figure 1]. Flush tests on two-dimensional echo with agitated saline through the left jugular catheter showed that the catheter was draining into right atrium [Figure 2]. When patient was taken for computed tomography cerebral angiography, the neck vessel angiography was also done which on venous reconstruction showed that there were no anomalies in the venous system, but the catheter tip was seen entering the left internal mammary vein (IMV) [Figure 3]. Later the central line was removed and replaced at a different location (since it was not showing CVP trace, and there was no backflow of blood through the port). Figure 1 Central venous catheter in the left internal jugular vein appears to be entering left atrium Figure 2 Agitated saline flush through the central port of the catheter showing bubbles in the right atrium Figure 3 Angiogram of neck showing left central venous catheter entering into left internal mammary vein The incidence of CVC malposition during IJV cannulation is around 2%.[1] There have been very few reported cases of accidental left IMV cannulation in the past.[2] CVC, which are misdirected into tributaries of central veins, are more common during central venous cannulation of the left side.[3] Reason may be due to the left brachiocephalic vein, which is anatomically longer and left smaller tributaries anastomose with the brachiocephalic vein opposite to the orifice of the left jugular vein.[4] Internal mammary vein receives the anterior intercostal veins and some abdominal branches, later drain into the brachiocephalic vein behind the sternal end of the clavicle and the first costal cartilage. Portal hypertension and portal to systemic collateral circulation dilates the IMV causing a higher risk of malpositioning of the catheter, which in our patient did not have any of these complaints. Complication related to IMV placement includes laceration of IMV with massive hemothorax and altered patency of the vein.[2,5] Ultrasound might reduce the complications associated with insertion, but chest X-ray would be needed to confirm the tip of catheter positioning.

Hemodynamic Monitoring in the ICU

This review examines the most commonly used hemodynamic monitoring devices in the intensive care unit. After a brief review of some important issues in hemodynamic monitoring, a variety of monitoring systems are considered, including arterial catheters, pulmonary artery catheters (PACs), less invasive hemodynamic monitors, central venous oxygen saturation (ScvO2) monitors, and point-of-care (POC) echocardiography. For each system, the basic operating principles, indications and limitations of use, complications, key issues in data interpretation, and evidence regarding utility in patient care are reviewed. Figures depict the distinction between correlation and agreement, a representative Bland-Altman plot, a square wave test, PAC waveforms, principles of pulmonary artery occlusion pressure measurement, measuring pulmonary artery occlusion pressure at end-exhalation, right atrial and ventricular pressure waveform, pulmonary artery pressure waveform, potential pulmonary artery occlusion waveforms, west zones of the lung and the pulmonary artery occlusion pressure measurements, and POC echocardiography. Tables outline landmarks during insertion of the PAC from the internal jugular and subclavian vein insertion sites; indications, contraindications, and complications of PAC insertion; a comparison of less invasive hemodynamic monitors; reasons for decreased mixed or ScvO2; and indications and contraindications for transesophageal echocardiography. This review contains 12 highly rendered figures, 7 tables, and 95 references.

Endovascular evaluation and treatment of intrahepatic portosystemic shunts in dogs: 100 cases (2001–2011)

To evaluate short- and long-term outcome following endovascular treatment of intrahepatic portosystemic shunts in dogs. Retrospective case series. 100 dogs. All patients had angiographic evaluation with or without endovascular shunt attenuation. The medical records were reviewed for pertinent data, complications, outcome, and survival time. 95 dogs with congenital intrahepatic portosystemic shunts received 111 procedures (83% [79/95] had 1 treatment, and 17% [16/95] had > 1 treatment; 5 dogs had no treatment because of excessive portal venous pressure-central venous pressure gradients). Angiography identified 38 right, 33 left, and 19 central divisional single shunts (n = 90) and 10 complex or multiple shunts. Partial shunt attenuation was performed in 92 dogs by means of caval stent placement and insertion of thrombogenic coils within the shunt, and 3 had complete acute shunt occlusion. Major intraoperative complications (3/111 [3%]) included temporary severe portal hypertension in 2 dogs and gastrointestinal hemorrhage in 1 dog. Major postoperative (< 1 week after surgery) complications (14/111 [13%]) included seizures or hepatoencephalopathy (7/111 [6%]), cardiac arrest (2/111 [2%]), jugular site bleeding (2/111 [2%]), pneumonia (1/111 [1%]), suspected portal hypertension (1/111 [1%]), and acute death (1/111 [1%]). Median follow-up time was 958 days (range, 0 to 3,411 days). Median survival time for treated dogs was 2,204 days (range, 0 to 3,411 days). Outcome was considered excellent (57/86 [66%]) or fair (13/86 [15%]) in 70 of 86 (81%) treated dogs. Results suggested that endovascular treatment of intrahepatic shunts in dogs may result in lower morbidity and mortality rates, with similar success rates, compared with previously reported outcomes for open surgical procedures. Gastrointestinal ulceration was a common finding among this population of dogs, and lifelong gastroprotectant medications are now recommended.

Use of a national continuing medical education meeting to provide simulation-based training in temporary hemodialysis catheter insertion skills: a pre-test post-test study.

BackgroundSimulation-based-mastery-learning (SBML) is an effective method to train nephrology fellows to competently insert temporary, non-tunneled hemodialysis catheters (NTHCs). Previous studies of SBML for NTHC-insertion have been conducted at a local level.ObjectivesDetermine if SBML for NTHC-insertion can be effective when provided at a national continuing medical education (CME) meeting. Describe the correlation of demographic factors, prior experience with NTHC-insertion and procedural self-confidence with simulated performance of the procedure.DesignPre-test – post-test study.Setting2014 Canadian Society of Nephrology annual meeting.ParticipantsNephrology fellows, internal medicine residents and medical students.MeasurementsParticipants were surveyed regarding demographics, prior NTHC-insertion experience, procedural self-confidence and attitudes regarding the training they received. NTHC-insertion skills were assessed using a 28-item checklist.MethodsParticipants underwent a pre-test of their NTHC-insertion skills at the internal jugular site using a realistic patient simulator and ultrasound machine. Participants then had a training session that included a didactic presentation and 2 hours of deliberate practice using the simulator. On the following day, trainees completed a post-test of their NTHC-insertion skills. All participants were required to meet or exceed a minimum passing score (MPS) previously set at 79%. Trainees who did not reach the MPS were required to perform more deliberate practice until the MPS was achieved.ResultsTwenty-two individuals participated in SBML training. None met or exceeded the MPS at baseline with a median checklist score of 20 (IQR, 7.25 to 21). Seventeen of 22 participants (77%) completed post-testing and improved their scores to a median of 27 (IQR, 26 to 28; p < 0.001). All met or exceeded the MPS on their first attempt. There were no significant correlations between demographics, prior experience or procedural self-confidence with pre-test performance.LimitationsSmall sample-size and self-selection of participants. Costs could limit the long-term feasibility of providing this type of training at a CME conference.ConclusionsDespite most participants reporting having previously inserted NTHCs in clinical practice, none met the MPS at baseline; this suggests their prior training may have been inadequate.