Jugular Venous Cannula Research Articles

Temporary venovenous extracorporeal membrane oxygenation after cardiopulmonary bypass in minimally invasive cardiac surgery via right minithoracotomy.

In minimally invasive cardiac surgery, it can be difficult at times to maintain adequate oxygenation with single-lung ventilation after weaning from cardiopulmonary bypass (CPB), and intermittent double-lung ventilation is required during hemostasis. Venovenous extracorporeal membrane oxygenation (VV-ECMO) after weaning from CPB eliminates the necessity of overinflation of the left lung and intermittent double-lung ventilation and enables secure and fast hemostasis. We investigated the effectiveness and safety of temporary VV-ECMO in MICS. Between May 2018 and March 2021, 149 patients underwent temporary VV-ECMO during minimally invasive cardiac surgery in our institutions. After weaning from CPB, the arterial circuit was reconnected to the right internal jugular venous cannula, the femoral venous cannula was pulled down by 20cm, and VV-ECMO was established using the CPB machine and cannulas. After starting VV-ECMO, we administered protamine and performed hemostasis. Operative data and outcomes were retrospectively reviewed. The mean VV-ECMO time and flow were 26 ± 13minutes and 2.38 ± 0.40L/m2, respectively. There was no thrombus in the CPB circuit, including the oxygenator. The trans-oxygenator pressure gradient index at the end of VV-ECMO significantly correlated with that at the start of VV-ECMO (r=0.88; 95% CI, 0.79-0.94; P=.01). The 30-day mortality rate was 2.0%. The incidences of unilateral pulmonary edema, prolonged ventilation, and re-exploration for bleeding were 2.7%, 5.4%, and 2.0%, respectively. Temporary VV-ECMO is safe and useful to maintain single-lung ventilation without overinflation after weaning from CPB for secure and fast hemostasis in minimally invasive cardiac surgery. No thrombotic event was found during temporary VV-ECMO without heparinization.

Integrative respiratory support during thoracoabdominal aortic aneurysm repair in a patient with severe lung disease: a case report

BackgroundThoracoabdominal aneurysm repair is a highly complicated procedure, especially among patients with severe lung disease, resulting in respiratory problems during and after the surgery. Herein, we designed a novel intraoperative respiratory support to address this.Case presentationAn open thoracoabdominal aortic aneurysm repair was performed on a 65-year-old man who had severe chronic obstructive pulmonary disease with a giant right lung bulla. One-and-a-half lung ventilation by left lower lobe blockade was maintained during the operation to avoid right barotrauma. Cardiopulmonary bypass (CPB) was established with venous cannulas in the right internal jugular vein and left femoral vein for elective venovenous extracorporeal membrane oxygenation (VV-ECMO). After aortic repair and withdrawal from CPB, the VV-ECMO was consecutively initiated using the same circuit by connecting the arterial cannula to the right internal jugular venous cannula. The patient maintained adequate oxygenation during hemostasis under the support of VV-ECMO after protamine was administered. He was weaned from VV-ECMO in the operating room and discharged without any complications.ConclusionPartial bronchial blockage and intraoperative VV-ECMO using the same circuit of CPB were useful methods for severe lung disease during a thoracoabdominal aortic repair.

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Hybrid and parallel extracorporeal membrane oxygenation circuits

Hybrid and parallel extracorporeal membrane oxygenation circuits

Differential hypoxemia during venoarterial extracorporeal membrane oxygenation.

Venoarterial extracorporeal membrane oxygenation, indicated for severe cardio-respiratory failure, may result in anatomic regional differences in oxygen saturation. This depends on cannulation, hemodynamic state, and severity of respiratory failure. Differential hypoxemia, often discrete, may cause clinical problems in peripheral femoro-femoral venoarterial extracorporeal membrane oxygenation, when the upper body is perfused with low saturated blood from the heart and the lower body with well-oxygenated extracorporeal membrane oxygenation blood. The key is to diagnose and manage fulminant differential hypoxemia, that is, a state that may develop where the upper body is deprived of oxygen. We summarize physiology, assessment of diagnosis, and management of fulminant differential hypoxemia during venoarterial extracorporeal membrane oxygenation. A possible solution is implantation of an additional jugular venous return cannula. In this article, we propose an even better solution, to drain the venous blood from the superior vena cava. Drainage from the superior vena cava provides superiority to venovenoarterial configuration in terms of physiological rationale, efficiency, safety, and simplicity in clinical circuit design.

Results of concomitant groin-free percutaneous temporary RVAD support using a centrifugal pump with a double-lumen jugular venous cannula in LVAD patients.

Modern left ventricular assist devices (LVAD) have evolved to become standard of care in severe heart failure (HF) patients. Right HF (RHF) is a major complication responsible for early mortality. Several techniques for temporary right ventricular assist device (t-RVAD) have been described before, baring relevant disadvantages such as limited mobilization or the need for re-thoracotomy. We describe the results of an alternative technique for t-RVAD using the Tandem Heart™ with ProtekDuo™ cannula. An institutional retrospective single centre outcome analysis was performed including all permanent LVAD recipients with concomitant groin-free t-RVAD support. Between October 2015 and September 2017, 11 patients (10 male, 90.9%) were included. Preoperative NYHA class was 3.8±0.75 and INTERMACS class 3.5±1.5. Four (36.4%) patients were already on mechanical circulatory support (MCS) at time of implantation with 4 (36.4%) patients already on inotropic support. All LVAD implantations were performed on-pump and 3 cases (27.3%) were re-do cases. Mean t-RVAD duration was 16.8±9.5 days. Ten patients (90.9%) could be weaned from temporary RVAD support, 1 patient deceased on support. Mean ICU stay was 23.8±16.5 days, while 30-day survival was 72.7%. Follow-up was complete with 214.7±283 days. Three patients (27.3%) died following multi-organ failure (MOF), 1 patient (9.1%) following intracranial bleed 12 days after t-RVAD explantation. No severe t-RVAD associated complications were observed. Our technique allows for safe groin-free t-RVAD providing all advantages of percutaneous implantation including complete mobilization and bedside explantation without any need for operation.

Letter to the editor on "Early and Mid-Term Outcome of Pediatric Congenital Mitral Valve Surgery".

Dear Editor, We read with great interest the study by Baghaei et al., and we congratulate the researchers for the noteworthy objective and results (1). The author reviewed 100 consecutive pediatric patients with congenital mitral valve disease that underwent mitral valve surgery through median sternotomy. Although in this study, most of the population was very young (mean age of 42.4 months, age range of 1 - 156 months, with 26 patients under one year old), we would like to highlight that today, minimally invasive surgery (MIS) can also be a feasible and safe tool in cases of congenital mitral valve disease in children. Previously published reports have already shown excellent results of MIS in mitral valve disease in adults (2, 3). However nowdays, there is a growing interest also in MIS for pediatric patients. Most of the reports in the pediatric literature concern atrial septal defect (ASD) closures or procedures with robotic surgical systems on extracardiac lesions; few reports show MIS applied to ventricular septal defect closures or to more complex defects (4-7). Very little has been reported on MIS used in the treatment of congenital mitral valve disease in pediatric patients (8). In 2013, we described the case of a 13-year-old child that underwent mitral prosthesis replacement through a right minithoracotomy using a port-access platform with peripheral cannulation and an endo-aortic balloon catheter for aortic clamping. The patient had undergone three previous cardiac surgeries (9). Venous drainage was obtained with double jugular and femoral vein cannulation. The jugular venous cannula (14 F DLP cannula; Medtronic, Minneapolis, Minnesota, USA) was placed percutaneously, whereas the femoral cannula (19 F Bio Medicus, Medtronic) was inserted through the groin incision. The right femoral artery was cannulated with a 21 F arterial Y-cannula (EndoReturn; Edwards Lifesciences, Irvine, California, USA). Correct positioning of the cannulae and of the endoclamping balloon were confirmed under transesophageal echocardiogram guidance. Concerns regarding MIS in pediatric patients are mainly related to the risk of inadequate flow caused by peripheral cannulae in small vessels. Our case report demonstrated the feasibility of a mitral valve procedure with peripheral cannulation and endo-aortic balloon clamping even in children; moreover, it allowed to avoid a reentry sternotomy with the associated risk of cardiac injury. The use of MIS in pediatric patients with congenital mitral valve disease is certainly limited by surface area and by the diameter of the femoral vessels; however, we believe that this tool must be taken into consideration during the in the surgical planning processes and surgical planning processes for younger patients.

Percutaneous Cannulation in Predominantly Venoarterial Extracorporeal Membrane Oxygenation by Intensivists

Critical Care Medicine www.ccmjournal.org e595 The authors reply: The letter by Burrell et al (1) describing the percutaneous cannulation experience by intensivists at Alfred Hospital provides important information for intensivists involved in extracorporeal life support (ECLS) programs and nicely complements our reported experience (2). Our ECLS program has historically provided predominantly respiratory support, and our cardiac support experience is more limited. Our ECLS experience consists mostly of venovenous cannulation with a smaller venoarterial cohort. Burrell et al (1) describe their cannulation experience, which includes a large venoarterial cohort. Aspects of the Alfred Hospital experience deserve mention. The first is their success with arterial cannulation with a low complication rate. Arterial cannulation entails more inherent risk than venous because arterial injury can lead to substantial more morbidity than venous injury. The 8% arterial complication rate reported, although higher than their venous rate (2%), is not unexpected and would not be considered excessive. Some of their complications required surgical management, so the availability of surgical services would seem advisable. Another aspect is the larger number of intensivists (16) available to perform cannulations. Although this would seem to dilute the experience of each intensivist, the approach of having more than one intensivist cannulating a given patient (as we do) increases the exposure to the procedure and helps maintain cannulation skills. secured. A second patient’s internal jugular venous access cannula was accidentally dislodged and removed but was resecured without major consequence. Overall average ECMO duration was 4 ± 4 days for VA ECMO and 14 ± 4 days for VV ECMO. Survival to hospital discharge was 73 of 122 (60%) for VA ECMO (including extracorporeal CPR) and 32 of 45 (71%) for VV ECMO. In total, seven of 167 patients (4%) had hemorrhagic or ischemic stroke, and there was one blood stream infection, and one confirmed cannula related infection. In conclusion, intensivist-led cannulation is also possible for a predominantly VA ECMO service and is associated with an acceptable complication rate. The authors have disclosed that they do not have any potential conflicts of interest.

Autophagy in pulmonary macrophages mediates lung inflammatory injury via NLRP3 inflammasome activation during mechanical ventilation.

The inflammatory response is a primary mechanism in the pathogenesis of ventilator-induced lung injury. Autophagy is an essential, homeostatic process by which cells break down their own components. We explored the role of autophagy in the mechanisms of mechanical ventilation-induced lung inflammatory injury. Mice were subjected to low (7 ml/kg) or high (28 ml/kg) tidal volume ventilation for 2 h. Bone marrow-derived macrophages transfected with a scrambled or autophagy-related protein 5 small interfering RNA were administered to alveolar macrophage-depleted mice via a jugular venous cannula 30 min before the start of the ventilation protocol. In some experiments, mice were ventilated in the absence and presence of autophagy inhibitors 3-methyladenine (15 mg/kg ip) or trichostatin A (1 mg/kg ip). Mechanical ventilation with a high tidal volume caused rapid (within minutes) activation of autophagy in the lung. Conventional transmission electron microscopic examination of lung sections showed that mechanical ventilation-induced autophagy activation mainly occurred in lung macrophages. Autophagy activation in the lungs during mechanical ventilation was dramatically attenuated in alveolar macrophage-depleted mice. Selective silencing of autophagy-related protein 5 in lung macrophages abolished mechanical ventilation-induced nucleotide-binding oligomerization domain-like receptor containing pyrin domain 3 (NLRP3) inflammasome activation and lung inflammatory injury. Pharmacological inhibition of autophagy also significantly attenuated the inflammatory responses caused by lung hyperinflation. The activation of autophagy in macrophages mediates early lung inflammation during mechanical ventilation via NLRP3 inflammasome signaling. Inhibition of autophagy activation in lung macrophages may therefore provide a novel and promising strategy for the prevention and treatment of ventilator-induced lung injury.

Insertion and management of percutaneous veno‐venous bypass cannula for liver transplantation: a reference for transplant anesthesiologists

Surgical advances using the retrohepatic caval preservation technique in liver transplantation (LT) has significantly decreased the need for veno-venous bypass (VVB). However, VVB still remains a viable adjunct of LT. The venous return cannula has traditionally been inserted using a cut-down technique via the axillary vein, but this technique carries significant risks for lymphorrhea, infection, or nerve damage. Since 2001, our institution has routinely used VVB in adult LT surgery. Percutaneous insertion of an internal jugular venous return cannula is performed by the attending anesthesiologist. The aim of this report is to describe the method of insertion and management of a percutaneous veno-venous return cannula in the internal jugular vein during LT. In-depth detail as well as video clips will provide a reference for LT centers wishing to apply this method in their practice.

A survey of the use of ultrasound guidance in internal jugular venous cannulation*

It has been that suggested the use of two dimensional (2D) ultrasound to facilitate placement of central venous cannulae in the internal jugular vein improves patient safety and reduces complications. Since the introduction of the National Institute for Clinical Excellence Technology Appraisal Guideline Number 49 in 2002, promoting the use of ultrasound in placement of internal jugular venous cannulae, utilisation of ultrasound has increased throughout the United Kingdom. We report the findings of a postal survey of 2000 senior anaesthetists in the United Kingdom which enquired about their use of ultrasound for internal jugular vein cannulae placement. Only 27% use 2D ultrasound as their first choice technique, although 35% use it as their first choice when teaching. There was no significant difference in practice between those working within a sub specialty in anaesthesia. There continues to be discrepancies between the application of the guideline and how senior anaesthetists both site and teach the placement of internal jugular vein central venous cannulae.

Complications Associated with Percutaneous Placement of Venous Return Cannula for Venovenous Bypass in Adult Orthotopic Liver Transplantation†

Percutaneous large bore cannula placement during orthotopic liver transplantation (OLT) for use in venovenous bypass (VVB) has been reported to be a rapid and simple technique. It is, however, a technique that carries its own risks. The aim of the study was to investigate the incidence of complications related to the placement of a percutaneous venous return cannula and subsequent VVB in OLT. A retrospective review of 360 consecutive adult OLT patients during a period of 18 months (January 1, 2003 to June 30, 2004) was performed. The percutaneous venous cannula (18 Fr) was placed by an attending transplant anesthesiologist. The cannulation was attempted in 326 patients (90.6%). No cannulation was attempted on the subclavian veins. Internal jugular venous cannula placement was attempted but aborted in 6 patients (1.8%) due to technical difficulties. In 320 patients who received an internal jugular venous cannula, 313 (97.8%) underwent OLT without complication. The remaining 7 patients (2.2%) had complications. The operation was delayed for 1 patient due to suspected hemomediastinum. The other 6 complications were related to VVB: air embolism (2 patients), low flow rate (2 patients), hypotension (1 patient), and atrial fibrillation (1 patient). Successful OLT was eventually carried out in all the 7 patients and no mortality associated with internal jugular venous cannula placement or VVB was noted. In conclusion, percutaneous placement of a large bore venous return cannula for VVB during adult OLT can be performed with acceptable risk using a flexible 18-Fr cannula via the right internal jugular vein (IJV) by experienced attending transplant anesthesiologists.

Anthocyanin Absorption and Antioxidant Status in Pigs

The effect of a simultaneous intake of food or flavonoids on anthocyanins absorption and antioxidant status in pigs was investigated. Twelve male pigs at 27.1 +/- 0.7 kg BW fitted with jugular venous cannulae were maintained in individual metabolic crates. The animals were each given one of three dietary treatments in random order: blackcurrant powder (BC) to give a dose of 100 mg total ACNs/kg BW mixed either with water and sugar (Diet A), cereal (Weet-Bix), milk, and sugar (Diet B), or cereal, milk, sugar, and an additional flavonol (rutin, approximately 100 mg/kg BW) (Diet C). The four major anthocyanins of BC, delphinidin-3-glucoside, delphinidin-3-rutinoside, cyanidin-3-glucoside, and cyanidin-3-rutinoside, were identified and quantified by HPLC-PDA in all three diets. In the pig plasma, four peaks with a reversed pattern to those of anthocyanins in the BC extract were detected. The total amount of anthocyanins absorbed was not significantly different between the three diets, but the rate of absorption and subsequent decline was slower following administration of diet B and C than diet A. All three diets increased antioxidant capacity when measured by the FRAP assay but not when measured by the ORAC and non-protein ORAC assay. However, the increase was delayed and did not appear until 4 h after ingestion, at a time when plasma anthocyanin levels had returned to baseline. The present study demonstrates that the simultaneous intake of food or other flavonoids delays the absorption profile for anthocyanins. Our results also suggest that the increase in antioxidant capacity is not due to dietary anthocyanins but may be due to metabolites that result from anthocyanin consumption.

Ascorbic Acid (Vitamin C) and Iloprost Attenuate the Lung Injury Caused by Ischemia/Reperfusion of the Lower Extremities of Rats

The objectives of this study were to compare the protective effects of ascorbic acid and iloprost on lung injury caused by ischemia reperfusion (I/R) of the lower extremities of rats. Wistar albino rats (n = 34) were divided into five groups. In the I/R group (n = 6), the aorta was cross-clamped for 3 hr, followed by 1 hr of reperfusion. In the vitamin C group (n = 8), animals were pretreated with 100 mg/kg ascorbic acid via the left jugular vein before aortic cross-clamping. In the iloprost group (n = 8), animals were pretreated with 20 ng/(kg x min) iloprost by constant intravenous infusion via the left jugular venous cannula. In the sham group (n = 6), the abdomen was left open at the same period and a juguler venous line was established. In the control group (n = 6), lungs were removed and blood samples taken immediately after sternotomy. No treatment was given in this group. After both lungs were removed, biochemical parameters were measured and histopathological evaluation was made. Although the arterial blood pO2 and HCO3 levels were statistically significantly high in both the vitamin C and iloprost groups compared to the I/R group, plasma malondialdehyde (MDA) levels were significantly low. Meanwhile, the MDA levels in the lung tissue were significantly low in the vitamin C group compared to the I/R group. The MDA level in the lung tissue in the iloprost group was also low compared to the I/R group, but it was not statistically significant. The lungs of the I/R group displayed intense interstitial leukocytic infiltration in histopathological examination compared to the other groups. Pretreatment of animals with iloprost and vitamin C significantly decreased the pulmonary injury characterized by decreased plasma leukocyte sequestration. The results suggest that both vitamin C and iloprost are useful agents for attenuating the lung injury caused by increased oxidative stress and neutrophil accumulation after a period of I/R of the lower extremities.

Carotid artery pseudoaneurysm with Horner's syndrome: delayed complication of internal jugular venous cannulation

A58-year-old man presented to hospital with a 1-week history of left arm swelling. Two days after admission he became pyrexial. Chest X-ray revealed a right-sided effusion, which was an empyema. He further deteriorated and developed respiratory failure. He was intubated and ventilated. Right internal jugular venous cannulation was conducted to allow central venous pressure monitoring. He was transferred to intensive care, where he gradually improved and was weaned off ventilation. The right internal jugular venous cannula was removed without difficulty 9 days later. Four days after removal of the internal jugular venous catheter, miosis and moderate ptosis on the right side (Horner's syndrome) was noticed. The remainder of the cranial nerves were intact. A computed tomography scan (CT) of the head and neck was done to investigate the cause of the right Horner's syndrome and the left arm swelling. The CT scan (with contrast) showed an enlarged carotid artery (Figure 1). Ultrasonography showed this to be a 4 cm × 2.5 cm false aneurysm. The carotid artery pseudo aneurysm corresponded to the site of internal jugular vein cannulation. The scan did not reveal a cause for the swollen left arm, which was resolved gradually. Later he was referred to the vascular unit where he underwent angiography and successful stenting of the aneurysm.

INVITED COMMENTARY

INVITED COMMENTARY

Invited commentary

The concept of higher hematocrit maintained during cardiopulmonary bypass and circulatory arrest is becoming generally accepted, due in part to the innovative basic and clinical research from the group at Boston Children's Hospital, some of which is presented here.The authors of this manuscript easily convinced me that animals in the low hematocrit group have vasodilatation induced increased cerebral blood flow and pressure with evidence of decreased venous pH, which should signal the onset of cerebral anaerobic metabolism. Conversely, they give data that indicate an increased cerebral metabolic rate for oxygen-a counterintuitive result.They explain this unexpected finding as, “Perhaps more oxygen is needed to counteract acidosis due to the lower pH buffering capacity of the dilute blood.” It is my opinion that the experimental preparation is probably inadequate to obtain an accurate cerebral venous sample. In the pig, the brain is relatively small and has a blood supply of lesser magnitude than the large neck and skull-based muscles when compared to the human. Since the sagittal sinus was not sampled, the jugular venous cannula must be inserted well into the temporal bone to avoid contamination from the multiple systemic venous connections, which enter the jugular vein just below the exit from the skull. The authors do not explain how they verified this position of the catheter, thus leading me to believe that jugular vein cannula position must be at least one factor in explaining this odd result. While it is possible that CMRO2 is elevated in this experimental situation, it is more likely that despite higher flow, O2 delivery is reduced, resulting in cellular acidosis. This assertion has been confirmed by a number of previous studies, albeit using different methodology, as the authors mention in their discussion.Nevertheless, the main point of the manuscript is that higher hematocrits than have been traditionally accepted are generally safer, particularly in pediatric cardiac surgery. Their point is well taken and adds to the growing body of literature describing “best practices” in cardiopulmonary bypass. The concept of higher hematocrit maintained during cardiopulmonary bypass and circulatory arrest is becoming generally accepted, due in part to the innovative basic and clinical research from the group at Boston Children's Hospital, some of which is presented here. The authors of this manuscript easily convinced me that animals in the low hematocrit group have vasodilatation induced increased cerebral blood flow and pressure with evidence of decreased venous pH, which should signal the onset of cerebral anaerobic metabolism. Conversely, they give data that indicate an increased cerebral metabolic rate for oxygen-a counterintuitive result. They explain this unexpected finding as, “Perhaps more oxygen is needed to counteract acidosis due to the lower pH buffering capacity of the dilute blood.” It is my opinion that the experimental preparation is probably inadequate to obtain an accurate cerebral venous sample. In the pig, the brain is relatively small and has a blood supply of lesser magnitude than the large neck and skull-based muscles when compared to the human. Since the sagittal sinus was not sampled, the jugular venous cannula must be inserted well into the temporal bone to avoid contamination from the multiple systemic venous connections, which enter the jugular vein just below the exit from the skull. The authors do not explain how they verified this position of the catheter, thus leading me to believe that jugular vein cannula position must be at least one factor in explaining this odd result. While it is possible that CMRO2 is elevated in this experimental situation, it is more likely that despite higher flow, O2 delivery is reduced, resulting in cellular acidosis. This assertion has been confirmed by a number of previous studies, albeit using different methodology, as the authors mention in their discussion. Nevertheless, the main point of the manuscript is that higher hematocrits than have been traditionally accepted are generally safer, particularly in pediatric cardiac surgery. Their point is well taken and adds to the growing body of literature describing “best practices” in cardiopulmonary bypass.

Percutaneous bypass cannulae can interfere with rapid infusion during liver transplantation

VENOVENOUS BYPASS (VVB) may be used during orthotopic liver transplantation (OLT) to maintain adequate preload when blood return to the heart is interrupted by cross-clamping of the inferior vena cava. Traditionally, when VVB is used, 1 drainage cannula is inserted via surgical cutdown into a femoral vein, and another is used to cannulate the portal vein directly. A centrifugal pump is used to aspirate venous blood from these sites and return it through a cannula inserted via surgical cutdown into an axillary vein. To avoid the complications of surgical cutdowns, percutaneous VVB has been used. 1 Tisone G Mercadante E Dauri M et al. Surgical versus percutaneous technique for veno-venous bypass during orthotopic liver transplantation: A prospective randomized study. Transplant Proc. 1999; 31: 3162-3163 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar , 2 Frenette L Cox J Singer D et al. Five years of experience with percutaneous cannula for establishing venous bypass access in orthotopic liver transplantation. Transplant Proc. 1996; 28: 2974-2977 PubMed Google Scholar , 3 Manas DM Gibbs P Talbot D et al. Use of percutaneously placed catheters for venovenous bypass in orthotopic liver transplantation. Transplantation. 1996; 62: 144-145 Crossref PubMed Scopus (3) Google Scholar , 4 Spiekermann BF Bogdonoff DL Hershey JE McLaughlin JD A method for percutaneous cannulation for veno-veno bypass during orthotopic liver transplantation. Anesth Analg. 1995; 80: 432-433 PubMed Google Scholar , 5 Scherer R Erhard J Giebler R et al. Percutaneous portofemoro-subclavian venovenous bypass during orthotopic liver transplantation. Transplantation. 1994; 57: 472-473 Crossref PubMed Google Scholar , 6 Scherer R Giebler R Schmutzler M et al. Effect of high shunt flows during portofemoro-subclavian venovenous bypass in human orthotopic liver transplantation. Transplant Proc. 1993; 25: 2591 PubMed Google Scholar , 7 Washburn WK Lewis WD Jenkins RL Percutaneous venovenous bypass in orthotopic liver transplantation. Liver Transpl Surg. 1995; 1: 377-382 Crossref PubMed Scopus (9) Google Scholar , 8 Ozaki CR Langnas AN Bynon JS et al. A percutaneous method for venovenous bypass in liver transplantation. Transplantation. 1994; 57: 472-473 Crossref PubMed Google Scholar , 9 Scherer R Giebler R Erhard J et al. A new method of veno-venous bypass during human orthotopic liver transplantation. Anaesthesia. 1994; 49: 398-402 Crossref PubMed Scopus (15) Google Scholar , 10 Johnson SR Marterre WF Alonso MH Hanto DW A percutaneous technique for venovenous bypass in orthotopic cadaver liver transplantation and comparison with the open technique. Liver Transpl Surg. 1996; 2: 354-361 Crossref PubMed Scopus (16) Google Scholar Although these reports all use at least 1 percutaneous cannula in the VVB circuit, they vary in their choice of cannulation sites, types and sizes of percutaneous cannulae, and VVB circuit configuration. The authors' VVB technique also varies from what has been reported. The authors routinely insert percutaneously a left femoral venous drainage cannula and a right internal jugular (RIJ) venous return cannula. The RIJ cannula serves a dual role as the major conduit for intravenous infusions from the rapid infusion system (RIS) (Haemonetics Corporation, Braintree, MA); this eliminates the need for additional large-bore intravenous access. In the following case, an unusually high VVB flow rate limited the maximal intravenous infusion rate of the RIS.

Percutaneous technique for venovenous bypass including a heat exchanger is safe and reliable in liver transplantation.

We have introduced and evaluated several modifications of the conventional venovenous bypass (VVBP) in 29 adult patients undergoing liver transplantation (OLT). A percutaneous technique for insertion of a jugular venous return cannula and a femoral vein cannula was applied. The inferior mesenteric vein (IMV) was used for splanchnic decompression, which facilitated dissection of the recipient liver and allowed portal anastomosis to be performed without disconnecting the portal bypass. A heat exchanger was introduced into the bypass circuit to prevent heat loss. The percutaneous technique prevented complications related to dissection in the axilla and groin. Hemodynamic characteristics corresponded to those found using the traditional technique. Complications related to the VVBP were seen in only one patient in whom the femoral catheter was accidentally introduced into the femoral artery. We conclude that percutaneous cannulas, use of the IMV for splanchnic decompression and the introduction of a heat exchanger offer significant benefits and that they are safe and reliable.

Induction of uterine activity with oxytocin in late pregnant rats replicates the expression of c-fos in neuroendocrine and brain stem neurons as seen during parturition.

We investigated whether delivery could be induced with pulsatile oxytocin and whether such treatment activated neurons in the supraoptic nucleus (SON) and putative afferent neurons in the nucleus tractus solitarii and ventrolateral medulla, as seen during spontaneous parturition. Rats were implanted with a jugular venous cannula 1 day before the expected term and on the next morning were given a pulse of oxytocin or saline every 10 min for 4 h. Pulses of 10 and 20 mU oxytocin induced delivery in 77% (14 of 18) of rats, whereas none of the control animals (0 of 9) gave birth during the treatment. Lower doses of oxytocin were not effective at this time in inducing delivery. Animals were killed either before (prepartum groups) or during (parturient groups) delivery, and the brains were processed for immunocytochemistry. Oxytocin treatment induced Fos expression in SON and brain stem neurons in both parturient rats and rats in which parturition was not induced. Fos expression in all sites was significantly higher than that in control prepartum rats, but was similar in extent and distribution to that in spontaneous parturient rats. In the brain stem, a substantial proportion of Fos-immunoreactive cells contained tyrosine hydroxylase-like immunoreactivity, and the number of these cells was increased in response to oxytocin treatment. As only very few Fos-immunoreactive nuclei in either the SON or the nucleus tractus solitarii were observed in virgin rats injected with oxytocin, we suggest that intermittent oxytocin injections in late pregnant rats induce strong uterine activity, which can stimulate magnocellular and putative afferent neurons even before the expulsion of pups.