Cannulation Method Research Articles

Preoperative computed tomography in the planning of median resternotomy in children

The capabilities of computed tomography (CT) in the diagnosis of mediastinal adhesions and measuring the density of adhesions when planning midline resternotomy in children were assessed, and the effect of preoperative CT on the incidence of surgical complications was studied. According to several authors, the frequency of resternotomies in cardiac surgery is up to 20% of the total number of surgeries per year and is accompanied by significant difficulties in the isolation of the heart and vessels. In pediatric cardiac surgery, complex congenital heart disease (CHD) mostly requires a staged approach. The staging of complex CHD correction and the need for repeated surgeries in most cardiac defects make the problem of safe repeated surgical access urgent. Postoperative adhesions are one of the most acute problems in modern cardiac surgery. The formation of adhesions is an inevitable reaction of the body after primary cardiac surgery. Massive adhesions that develop after surgery most commonly lead to adhesion of the heart and major great vessels to the posterior surface of the sternum. These changes are especially pronounced in children due to the high reactivity of the body and the lack of technical possibility and expediency of pericardial suturing after surgery. Rough adhesions during resternotomy complicate the cardiac surgeons task and increase the risk of complications. The main dangers are damage to various structures in the thorax such as the right and left heart, aorta, coronary arteries, pulmonary artery, and brachiocephalic vein. The diagnosis of postoperative adhesions in the mediastinum before resternotomy is difficult. CT has the widest diagnostic capabilities for assessing mediastinal adhesions. When performing CT as a part of preoperative resternotomy planning, it is important to examine the mediastinal topography, assess the degree of adjacency of the pericardium and mediastinal structures, determine the presence and density of adhesions, and assess patency and diameter of great vessels to select cannulas and cannulation methods necessary for emergency start of cardiopulmonary bypass (CPB) in cardiac trauma. These criteria are important when planning midline resternotomy to reduce the risks of traumatization of cardiac structures and great vessels and allow correction of surgical tactics and timely preventive surgical measures. Depending on the density, extent, and localization of adhesions, the cardiolysis technique and cannulation of great vessels required for initiation of emergency CPB may be changed. The use of preoperative CT when planning midline resternotomy in children allows to predict the risks of damage of cardiac structures and great vessels and visualize adhesive bands and measure their density, which helps the surgeon to adjust surgical tactics regarding the method and volume of cardiolysis and assess patency and diameter of great arteries and veins, thus determining the cannulation method and cannula diameter in advance if urgent CPB is needed. Therefore, standardization of CT description protocols for midline resternotomy planning with assessment of key criteria is an urgent task and requires further development.

P87: Fracture Of A Dual Lumen Protekduo Cannula With Ventricular Perforation And Tamponade In A Recovery COVID-19 Patient

Background: In the absence of formal registry data anecdotal reports of cannula complications provide the only mechanism of risk assessment in the extended use of short term mechanical circulatory support devices. We report an unrecognized cannula fracture with perforation of the right ventricular apex and subsequent tamponade at the time of de-cannulation. Methods and Results: Patient is a 38 yo AAF with a history of asthma diagnosed with COVID 19 (nasal PCR) and admitted to an OSH with hypoxia (O2 sat 70%) and progressive dyspnea on exertion requiring HFNC and subsequent deployment of a right internal jugular 29 Fr Protek-DUO double lumen cannula with in-line oxygenator for venovenous ECMO respiratory support. After 36 days of VV ECMO support and mechanical ventilation, the patient was transferred with a diagnosis of COVID ARDS for transplant evaluation. Fourteen days post-transfer the patient was ambulatory and no longer required mechanical ventilation. No flow related issues were noted during the entire period of ECMO support (flow 2.8 to 3.4 L/min, delta P 20 mmHg or less, single oxygenator exchange on ECMO day 38). On ECMO day 67 the patients CxR was clear (Figure 1) and the RIJ cannula was removed without complication. Approximately two minutes after cannula removal the patient became unresponsive with tachycardia and hypotension (SBP 60 mmHg) which initially responded to volume resuscitation. With progressive loss of systolic blood pressure chest compressions were started with complete hemodynamic collapse. A transthoracic ECHO suggested tamponade and the chest was opened at the bedside demonstrating a chronic appearing hematoma with blood extravasation at the apex of the right ventricle (Figure 2). Bleeding was controlled with a single prolene stitch. Subsequent examination of the cannula demonstrated a fracture in the wire reinforced cannula at the point where the catheter transitioned from the apical RV into the RVOT (Figure 3). Conclusion: Given the progressive pulmonary hypertension frequently seen with prolonged COVID ECMO support, the RA to PA dual-lumen cannula has proven an effective MCS strategy (1) with survival advantage when compared to standard VV ECMO support (2). The Protek-DUO cannula was not designed for prolonged ambulatory MCS (> 60 days). Given the recent report of a seemingly identical cannula fracture event (3), clinicians should be aware of the potential for cannula fracture over time. Literature Cited (1) Mustafa AK, et al. (2020) ECMO for patients with COVID-19 in severe respiratory failure. JAMA Surg 155(10):990-992. (2) Saeed O, et al (2022) Outcomes by cannulation method for venovenous ECMO during COVID-19: a multicenter retrospective study. 46(8):1659-1668. doi: 10.1111/aor.14213. (3) Odish MF, et al (2022) Fracture right atrial-pulmonary artery cannula (Protek-DUO) in a 164-day extracorporeal membrane oxygenation bridge to lung transplant. doi: 10.1097/MAT.0000000000001879. Online ahead of print.

Coronary sinus cannulation as real time anatomical landmark to facilitate left bundle branch area pacing

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Left bundle branch area pacing (LBBAP) is an established form of conduction system pacing. Innovative fluoroscopic imaging technique with use of radio-opaque contrast in the right ventricle or using pre-mapped His potential has been advocated as an acquired road map to assist in implantation of LBBAP(1) lead. Purpose We aim to explore a different technique by cannulating the coronary sinus (CS) with a sheath and wire to provide real-time anatomical guidance of location of the base of the heart to facilitate more effective LBBAP in a consistent fashion. Methods Prior to LBBAP, the body of the CS is cannulated using an AL2 diagnostic angiographic catheter and a 0.035-inch glidewire. The wire is fixated externally, and fluoroscopic image is acquired before proceeding with deployment of the pacing lead onto an optimal ventricular septal position via standard right (RAO 30) and left anterior oblique (LAO 30) views. From August 2021 to October 2022, we enrolled 12 consecutive patients requiring pacemaker for standard indications and explored the CS cannulation method in delivering LBBAP with either steerable catheters or fixed shape sheaths. Thereafter, we analysed and described the success rates, immediate electrical and device parameters, procedural durations, and clinical events. Results 12 patients were studied. The mean age was 75 ± 13.07 years and 6 (50%) patients were male. 1 (8.3%) was for sinus nodal dysfunction, 10 (83.3%) for atrioventricular block and 1 (8.3%) for atrial fibrillation (AF) control with atrioventricular node ablation. Mean left ventricular ejection fraction was 54.17 ± 8.21 % and baseline QRS was 108.08 ± 23.20ms. LBBAP was successful in all 12 patients based on published criteria with a mean paced QRS duration of 115.25 ± 9.28 ms. The mean total procedure duration was 130.75 +/- 29.84 minutes and mean fluoroscopic duration was 23.17 ± 9.11 minutes. After 1st week post implant, the pacing threshold, sensing, and impedances were stable and acceptable in all the patients. There were no acute complications (e.g. pneumothorax, lead complications, lead dislodgements / perforations) during the periprocedural period. Conclusion(s) The CS cannulation method is a feasible, safe, and effective method to to provide real-time anatomical visualisation of the base of the heart. This facilitates the achievement for optimal LBBAP and can be adopted especially in difficult cardiac anatomies or rotated cardiac silhouettes identified on fluoroscopy.

Comparison between the long-axis in-plane and short-axis out-of-plane approaches for ultrasound-guided arterial cannulation: a meta-analysis and systematic review

BackgroundThe two most common methods for ultrasound-guided arterial cannulation are the long-axis in-plane (LA-IP) and short-axis out-of-plane (SA-OOP) approaches. However, it is uncertain which method is more advantageous. We conducted a meta-analysis of reported randomized clinical trials (RCTs) comparing the two techniques in terms of success rate, cannulation time, and complications.MethodsWe systematically searched PubMed, Embase, and the Cochrane Library database for RCTs comparing the LA-IP and SA-OOP techniques for ultrasound-guided arterial cannulation published from inception through April 31, 2022. The Cochrane Collaboration’s Risk of Bias Tool was used to evaluate the methodological quality of each RCT. Review Manager 5.4 and Stata/SE 17.0 were used to analyze the two primary outcome measures (first-attempt success rate and total success rate) and two secondary outcome measures (cannulation time and complications).ResultsA total of 13 RCTs with 1,377 patients were included. There were no significant differences in first-attempt success rate (risk ratio [RR], 0.93; 95% confidence interval [CI], 0.78–1.12; P = 0.45; I2 = 84%) and overall success rate (RR, 0.99; 95% CI, 0.95–1.02; P = 0.48; I2 = 57%). When compared with the LA-IP technique, the SA-OOP technique was associated with an increased incidence of posterior wall puncture (RR, 3.01; 95% CI, 1.27–7.14; P = 0.01; I2 = 79%) and hematoma (RR, 2.15; 95% CI, 1.05–4.37; P = 0.04; I2 = 63%). There was no significant difference in the incidence of vasospasm between techniques (RR, 1.26; 95% CI, 0.37–4.23; P = 0.07; I2 = 53%).ConclusionsThe present results suggest that the SA-OOP technique is associated with a higher incidence of posterior wall puncture and hematoma than the LA-IP technique, whereas success rates are similar for the two ultrasound-guided arterial cannulation techniques. These findings should be experimentally evaluated in a more rigorous manner due to high inter-RCT heterogeneity.

Morphology of the major duodenal papilla for the selection of advanced cannulation techniques in difficult biliary cannulation.

Morphology of the major duodenal papilla (MDP) influences the outcome of standard biliary cannulation. However, those data on advanced cannulation techniques are scarce. We aimed to study the impact of MDP morphology on the outcome of both standard and advanced cannulation methods. Images of naïve papilla were retrospectively reviewed and independently classified into 4 types (1: classic appearance, 2: small, 3: bulging, and 4: ridged papillae). All cannulation was started with guidewire cannulation. After failure, advanced cannulation including double guidewire (DG) and/or precut sphincterotomy (PS) was performed. Outcomes including success rate and complications were analyzed. A total 805 naïve papilla were included. The overall advanced cannulation rate was 23.2%. The MPD type 2 (OR 1.8, 95% CI 1.8-2.9) and type 4 (OR 2.1, 95% CI 1.1-3.8) required advanced cannulation technique at a higher rate than type 1. Type 3 significantly needed a higher proportion of PS when compared with type 1 (59.09% vs 27.03%, OR 3.90, 95% CI 1.51-10.06). Overall post-ERCP pancreatitis (PEP) was 8% and was not different among MDP types. PEP was significantly increased in difficult cannulation group (15.38% vs 5.71%, p-value < 0.001). Multivariate analysis demonstrated that DG independently increased risk of PEP (OR 3.6, 95% CI 2.0-6.6). MDP type 2 and type 4 were related to difficult cannulation. Although DG and PS can be used as advanced cannulation in all types, DG carries risk of PEP and PS may be preferred over DG in MDP type 3.

A Prospective Comparison of Ultrasound Guided Versus Palpation Method for Radial Artery Catheter Placement

Objectives: The objective of this study was to assess the effectiveness of ultrasound guided vs. conventional palpation method for radial artery cannulation in the operating room for patients undergoing elective open-heart operations. Methodology: This prospective observational study was carried at the National Institute of Cardiovascular Disease (NICVD) in Karachi and Sukkur. All cannulation procedures were performed by anesthesia residents (R-1). Two equal sized independent groups of patients based on radial artery cannulation technique, either ultrasound guided (USG) or conventional palpation method (CPM) were recruited. Artery cannulation success along with number of attempts, total duration, number of additional operators, need for change of site, and complications were recorded. Results: A total of 70 patients were recruited in each of the group, mean patient age was 52.43±13.53 years vs. 50.71 ± 14.1 years; p=0.605 with proportion of male patients as 65.7% (46) vs. 77.1% (54); p=0.290, for USG and CPM, respectively. Artery cannulation success rate was 74.3% (52) vs. 80% (56); p=0.569, mean number of attempts was 1.71±1.05 vs. 1.51±0.89; p=0.391, mean total duration was 7.76±3.78 minutes vs. 5.42 ± 8.2 minutes; p=0.131, mean number of additional operators was 0.74±0.44 vs. 0.89±0.32; p=0.128, need for change of site was 11.4% (8) vs. 2.9% (2); p=0.356, and complications were observed in 8.6% (6) vs. 2.9% (2); p=0.614 for USG and CPM, respectively. Conclusion: In this observational study, no significant differences were observed in the effectiveness of USG and CPM for radial artery cannulation when performed by newly inducted anesthesia residents.

High-Grade Staphylococcus lugdunensis Bacteremia in a Patient on Home Hemodialysis.

Staphylococcus lugdunensis (S lugdunensis) is a species of coagulase-negative Staphylococcus and a constituent of human skin flora. S lugdunensis has gained notoriety for its virulence, which resembles Staphylococcus aureus (S aureus). S lugdunensis is now recognized as an important nosocomial pathogen and cause of prosthetic device infections, including vascular catheter infections. A 60-year-old man with a history of uncontrolled type 2 diabetes mellitus and end-stage renal disease on home hemodialysis via arteriovenous fistula (AVF) presented to the emergency department for evaluation of subacute progressive low back pain. Initial laboratory tests were notable for elevated inflammatory markers. Magnetic resonance imaging with contrast of the thoracic and lumbar spine revealed abnormal marrow edema in the T11-T12 vertebrae with abnormal fluid signal in the T11-T12 disc space. Cultures grew methicillin-sensitive S lugdunensis. The patient's antibiotic regimen was narrowed to IV oxacillin. He was transitioned to IV cefazolin dosed 3 times weekly after hemodialysis and an outpatient dialysis center. Treatment of bacteremia caused by S lugdunensis or S aureus should be managed with prompt initiation of IV antistaphylococcal therapy, a thorough evaluation for the source of bacteremia as well as metastatic complications, and consultation with an infectious disease specialist. This case highlights AVF as a potential source for infection even without localized signs of infection. The buttonhole method of AVF cannulation was thought to be a major contributor to the development and persistence of our patient's bacteremia. This risk should be discussed with patients using a shared decision-making approach when developing a dialysis treatment plan.

Dose-dependent pharmacokinetics of midazolam in rats: influence of hepatic first-pass metabolism

To characterise the dose-dependent pharmacokinetics of midazolam and evaluate the intestinal and hepatic first-pass effects on midazolam in Sprague-Dawley rats, the concentrations and area under the concentration-time curve (AUC) of midazolam in the portal and systemic plasma were simultaneously determined with a double cannulation method. It was found that about 75% of the dose was left in the portal blood with different oral administration doses, while the bioavailability in the liver was 37.86% at 20 mg/kg, significantly higher than 9.16% at 2 mg/kg. The disproportional increase in AUC of midazolam and significant decrease in exposure of metabolites were observed in systemic plasma after hepatic portal vein administration. And in the in vitro study, the formation rate of the metabolites of midazolam significantly decreased when midazolam was at 300 μM compared with 100 μM. These results indicated that not only the saturation of first-pass metabolism but also the inhibition of hepatic metabolism is responsible for the nonlinear PK of midazolam. Thus, a rational dose should be chosen when midazolam is used as a probe in the drug-drug interaction study, particularly for orally administered drugs that undergo hepatic first-pass metabolism.

Clinical practice of emergency department-initiated extracorporeal cardiopulmonary resuscitation for cardiac arrest in adults.

Clinical practice of emergency department-initiated extracorporeal cardiopulmonary resuscitation for cardiac arrest in adults.

A novel method for repeated cerebrospinal fluid sampling and long-term monitoring of intracranial pressure in rats.

Cannulation implantation into the cisterna magna is an important procedure in cerebrospinal fluid (CSF) sampling and intracranial pressure (ICP) monitoring. The disadvantages of existing techniques include the risk of brain damage, compromised muscle mobility, and the complexity of the procedures. In the present study, the authors describe a modified, simple, and reliable procedure for long-term cannulation implantation into the cisterna magna in rats. The device consists of four parts: the puncture segment, the connection segment, the fixing segment, and the external segment. Intraoperative ICP monitoring and post-operative computed tomography (CT) scans were performed, which confirmed the accuracy and safety of this method. There were no limitations on the daily activities of the rats when long-term drainage was carried out for 1 week. This new technique offers an improved method of cannulation and will be a potentially useful method for CSF sampling and ICP monitoring in neuroscience research.

A randomized controlled trial comparing ultrasound-guided versus traditional palpatory methods of posterior tibial artery cannulation in adult patients.

The palpation method of posterior tibial artery cannulation has not yet been compared to ultrasound-guided posterior tibial artery cannulation in adults. This research examined whether using ultrasound to cannulate the posterior tibial artery enhances first-pass cannulation success and lowers total procedure time. In this randomized controlled experiment, 76 adult patients were included who were undergoing surgery under general anesthesia and required artery cannulation. Cannulation of the posterior tibial artery was performed utilizing either an ultrasound-assisted method (group U) or a palpation method (group P). Data were analyzed for cannulation success on the first attempt, number of cannulation attempts, assessment time, cannulation time, and total procedure time. The P group had a considerably shorter mean assessment time than the U group [14.29 ± 2.79 s vs 20.89 ± 2.70 s; p < .001]. Moreover, cannulation time was substantially longer in the P (29.20 ± 12.60 s) than in the U group (15.90 ± 6.50 s) (p < .001). The total procedure time remained statistically more in the P group than in the U group (p = 0.007). The rate of successful posterior tibial artery cannulation on the first attempt was comparable between the two groups (63.2% in the U and 55.3% in the P group, respectively; p = .484)]. The posterior tibial artery may be a suitable alternative to arterial cannulation for individuals with multiple failed attempts or difficult access. The application of ultrasound during posterior tibial artery cannulation in adult patients is safe and feasible and accompanied by a reduction in cannulation and total procedure time. The rate of first-attempt successful posterior tibial artery cannulation was comparable between the two groups.

Fluid–structure interaction simulation of visceral perfusion and impact of different cannulation methods on aortic dissection

Hemodynamics in aortic dissection (AD) is closely associated with the risk of aortic aneurysm, rupture, and malperfusion. Altered blood flow in patients with AD can lead to severe complications such as visceral malperfusion. In this study, we aimed to investigate the effect of cannulation flow on hemodynamics in AD using a fluid–structure interaction simulation. We developed a specific-idealized AD model that included an intimal tear in the descending thoracic aorta, a re-entry tear in the left iliac artery, and nine branches. Two different cannulation methods were tested: (1) axillary cannulation (AC) only through the brachiocephalic trunk and (2) combined axillary and femoral cannulation (AFC) through the brachiocephalic trunk and the right common iliac artery. AC was found to result in the development of a pressure difference between the true lumen and false lumen, owing to the difference in the flow rate through each lumen. This pressure difference collapsed the true lumen, disturbing blood flow to the celiac and superior mesenteric arteries. However, in AFC, the pressure levels between the two lumens were similar, and no collapse occurred. Moreover, the visceral flow was higher than that in AC. Lastly, the stiffness of the intimal flap affected the true lumen's collapse.

Development and application of a novel cervical lymph collection method to assess lymphatic transport in rats.

Background: Fluids, solutes and immune cells have been demonstrated to drain from the brain and surrounding structures to the cervical lymph vessels and nodes in the neck via meningeal lymphatics, nasal lymphatics and/or lymphatic vessels associated with cranial nerves. A method to cannulate the efferent cervical lymph duct for continuous cervical lymph fluid collection in rodents has not been described previously and would assist in evaluating the transport of molecules and immune cells from the head and brain via the lymphatics, as well as changes in lymphatic transport and lymph composition with different physiological challenges or diseases. Aim: To develop a novel method to cannulate and continuously collect lymph fluid from the cervical lymph duct in rats and to analyze the protein, lipid and immune cell composition of the collected cervical lymph fluid. Methods: Male Sprague-Dawley rats were cannulated at the carotid artery with or without cannulation or ligation at the cervical lymph duct. Samples of blood, whole lymph and isolated lipoprotein fractions of lymph were collected and analyzed for lipid and protein composition using commercial kits. Whole lymph samples were centrifuged and isolated pellets were stained and processed for flow cytometry analysis of CD3+, CD4+, CD8a+, CD45R+ (B220) and viable cell populations. Results: Flow rate, phospholipid, triglyceride, cholesterol ester, free cholesterol and protein concentrations in cervical lymph were 0.094 ± 0.014mL/h, 0.34 ± 0.10, 0.30 ± 0.04, 0.07 ± 0.02, 0.02 ± 0.01 and 16.78 ± 2.06mg/mL, respectively. Protein was mostly contained within the non-lipoprotein fraction but all lipoprotein types were also present. Flow cytometry analysis of cervical lymph showed that 67.1 ± 7.4% of cells were CD3+/CD4+ T lymphocytes, 5.8 ± 1.6% of cells were CD3+/CD8+ T lymphocytes, and 10.8 ± 4.6% of cells were CD3-/CD45R+ B lymphocytes. The remaining 16.3 ± 4.6% cells were CD3-/CD45- and identified as non-lymphocytes. Conclusion: Our novel cervical lymph cannulation method enables quantitative analysis of the lymphatic transport of immune cells and molecules in the cervical lymph of rats for the first time. This valuable tool will enable more detailed quantitative analysis of changes to cervical lymph composition and transport in health and disease, and could be a valuable resource for discovery of biomarkers or therapeutic targets in future studies.

“MINI-MIDLINE”: VASCULAR ACCESS IN SPECIFIC SITUATIONS

Peripheral intravenous catheters (PIVCs) play a particularly important role in Emergency Departments (ED), during the administration of anesthesia in the operating room, in post-operative and monitored wards of various specialties, in cases when the patient requires access to the vein due to intensive and varied intravenous therapy. Using short peripheral intravenous catheters carries a high risk of complications, despite their prevalence and staff experience. Patients with DIVA require a comprehensive approach not only during elective (scheduled) intravenous therapy, but also in the aforementioned departments and during emergency interventions in case of deterioration in Non-Intensive-Care-Units. Emergency intravenous access is required for the implementation of many procedures, so it is reasonable to introduce methods that increase the safety and quality of therapy. Midline catheters (MCs) are becoming increas¬ingly popular in Poland. However, based on our experience, they are not the optimal solution in every situation. “Mini-midlines” can be clinically useful in patients with DIVA whose therapy is expected to exceed 5 days. They may be applied in patients who require a secure and rapid insertion of the cannula into the vein and greater fluid flow than via a classic MC. Regardless of the equipment used, the ultrasound-guided mini-midline implantation procedure is simple and quick. Based on available research and experience at our centres, we follow a management regimen for patients who arrive in the ED, have no intravenous access and the team is faced with the clinical dilemma of choosing which cannulation method should be used. Proper patient enrollment and subsequent cannula maintenance increases the quality of care and patient satisfaction. It is advisable to introduce local protocols for selecting appropriate intravenous access and to run prospective studies regarding the topic under discussion.

Survival Outcome in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation Support: Early Experience from a University Hospital in Thailand.

Objective Extracorporeal membrane oxygenation (ECMO) is a relatively new technology used for life support in patients with cardiopulmonary failure from various causes. The objective of this study is to review the first 5-year experience in adopting this technology in a teaching hospital in southern Thailand. Methods The data of ECMO-supported patients in Songklanagarind Hospital, from the years 2014 to 2018, were retrospectively reviewed. Data sources were from electronic medical records and the database of the perfusion service. Parameters in focus included prior conditions and indications of ECMO, type of ECMO and cannulation method, complications during and after the treatment, and discharge statuses. Results A total of 83 patients received ECMO life support during the 5-year period and the number of cases per year increased. The proportion of venovenous: venoarterial ECMO in our institute was 49:34 cases and there were three cases who used ECMO as a part of cardiopulmonary resuscitation. Moreover, there were 57 cases who used ECMO for cardiac failure and 26 cases were for respiratory causes, while premature withdrawal was decided in 26 cases (31.3%). Overall survival from ECMO was 35/83 cases (42.2%) and survival to discharge was 32/83 (38.6%). During therapy, ECMO could restore serum pH to the normal range in all cases. Furthermore, those who used ECMO for respiratory failure had significantly higher survival probability (57.7%) when compared to the cardiac counterpart (29.8%, p -value = 0.03). Patients with younger ages also had significantly better survival outcomes. The most common complications were cardiac (75 cases, 85.5%), followed by renal (45 cases, 54.2%), and hematologic systems (38 cases, 45.8%). In those who survived to discharge, average ECMO duration was 9.7 days. Conclusion Extracorporeal life support is a technology that bridges the patients with cardiopulmonary failure to their recovery or definitive surgery. Despite the high complication rate, survival can be expected, especially in respiratory failure cases and relatively young patients.

Comparison of novel anteroposterior short-axis in-plane technique with conventional short-axis out-of-plane technique for ultrasound-guided internal jugular vein cannulation: A randomized-controlled trial.

Various ultrasound (US)-guided probe positioning and needle procedures have been described in the literature for cannulation of the internal jugular vein (IJV). In the present study, we compared the conventional short-axis out-of-plane (SAX-OOP) method with a novel anteroposterior short-axis in-plane (APSAX-IP) technique for IJV cannulation under US guidance. The APSAX-IP method of IJV cannulation has not been compared to other IJV cannulation techniques. A total of 104 patients above 18-year-old were randomly allocated to one of two groups - APSAX-IP or SAX-OOP and evaluated for US-guided IJV cannulation in either the operating room or critical care unit. The primary outcome of this research was the access time for IJV cannulation using both approaches. The secondary outcomes were the number of attempts of needle insertion, success rate, and complications of IJV cannulation. The access time for IJV cannulation was 13.0 (12.0-15.0) sec in the APSAX-IP group and 13.0 (12.0-14.0) sec in the SAX-OOP group; P = 0.947. The number of successful 1st attempts was 90.91%, and the 2nd attempts were 9.09% in the APSAX-IP group and 85.19% and 14.81% in the SAX-OOP group, respectively. Both techniques did not have any complications. We conclude that the US-guided APSAX-IP IJV cannulation method has comparable access time to the SAX-OOP technique.

Ultrasound guidance versus landmark method for peripheral venous cannulation in adults.

Ultrasound guidance versus landmark method for peripheral venous cannulation in adults.

Predictive factors of difficult biliary cannulation: An experience of a tunisian tertiary center

IntroductionSelective biliary cannulation is a prerequisite for a successful endoscopic retrograde cholangiopancreatography (ERCP). However, conventional biliary access can be difficult. The aims of our study were to determine the prevalence of difficult biliary cannulation (DBC) and its associated factors and to describe the efficiency and safety of used standard and advanced cannulation techniques. MethodsWe conducted a single-center retrospective study including all patients with naïve papilla who had an ERCP procedure in Gastroenterology department of Mohamed Taher Maamouri Hospital from June 2019 to December 2021. Efficiency was defined as successful selective deep biliary cannulation. DBC was defined based on the presence of one or more of the European Society of Gastrointestinal Endoscopy (ESGE) criteria (5-5-1): more than five cannulation attempts, more than 5 min before cannulation and more than one accidental passage in the wirsung. Prevalence was measured using ESGE 5-5-1 cutoffs and chinese set cutoffs 15-10-2. Predictors of DBC were sought by univariate and multivariate analysis (SPSS software, p significant if < 0.05). ResultsWe included 664 patients (mean age 62 years and sex ratio M/W = 0.8). Main indication for ERCP was choledocholithiasis (67%, n = 442) followed by malignant biliary stenosis (21%, n = 138). Based on ESGE criteria, prevalence of DBC was 42.62% (n = 283). Prevalence was 21.15% when 15-10-2 cutoffs are applied in trainee-involved procedure. Cumulative biliary success rate was 96.46%. Standard cannulation method achieved access in 98.2% while advanced methods permitted success in 92.2% in fistulotomy, 94.1% in papillotomy and 77.3% in transpancreatic sphincterotomy. Independent predictive factors of DBC in multivariate analysis were: Trainee presence OR 1.80 [1.24–2.65], SOD OR 4.71 [1.11–19.88], biliary stenosis found on imaging examinations (OR 2.53 [1.63–3.92], small papilla OR 4.09 [1.82–9.17] and difficult orientation of the papilla OR 14.90 [3.28–67.62]. ConclusionDBC is a frequent endoscopic situation. Predictors of DBC can be related to trainee involvement in the procedure, anatomical and clinical factors. A thorough understanding of these factors can actively contribute to ERCP management plans.

Suprapapillary Needle Knife Fistulotomy Versus Conventional Precut Sphincterotomy in Difficult Biliary Cannulation: A Retrospective Comparative Study.

Endoscopic retrograde cholangiopancreatography (ERCP) is an important therapeutic tool for many biliary diseases. Selective biliary cannulation is the first step of the treatment process. Needle knife fistulotomy (NKF) and conventional precut sphincterotomy (CPS) are widely used in difficult biliary cannulation. However, there are different results in their effectiveness and safety. This study aimed to compare both methods regarding cannulation success and adverse event profile. All eligible consecutive patients with naive papillae who underwent biliary ERCP by a single experienced endoscopist over a 3-year period were included retrospectively. The standard cannulation method with a guidewire-loaded sphincterotome was initially used for biliary cannulation in all patients. Cannulation was accepted as difficult in the case of failure of standard cannulation within 5 minutes or despite 5 attempts or insertion of the guidewire to the pancreatic duct 5 times. Three modalities in patients with difficult biliary cannulation were employed according to the structure and configuration of the papillae in addition to unintentional pancreatic cannulation: (1) NKF, (2) CPS, (3) Double guidewire technique or guidewire orientation/precut following pancreatic stenting. Latter was excluded to enable direct comparison between NKF and CPS groups. A total of 644 patients were recruited. Analyses were performed with 541 patients after the exclusion of 103 patients. Mean (SD) age was 60.4 (18.2) years, and 257 (47.5%) patients were male. While standard cannulation was successful in 366 (67.6%), difficult biliary cannulation was observed in 175 (32.4%) patients. NKF was performed in 101 (57.7%) patients, and cannulation success was 100% in the first ERCP session. In contrast, CPS was performed in 74 (42.3%) patients with a lower cannulation success rate (79.7%) than NKF ( P <0.001). Post-ERCP pancreatitis rate was higher in CPS (9.5%) than NKF group (3.0%, P =0.063). Bleeding and cholangitis were similar in both groups. In patients with difficult biliary cannulation with appropriate papillary structure and configuration, NKF should be used as the first choice in experienced hands because of high biliary cannulation success and low Post-ERCP pancreatitis risk.

Minimally Invasive Central Cannulation for Extracorporeal Life Support: The Uniportal and Subxiphoid Approach.

Extracorporeal life support (ECLS) for circulatory and/or respiratory failure is improving. Currently, invasive sternotomies or rib-spreading thoracotomies are used for central cannulation of the heart and great vessels. Although peripheral cannulation of the extremities is often used, this approach may result in immobility and unintentional dislodgement. Less invasive methods for central cannulation are needed to achieve long-term ECLS. The objective of this study was to develop 2 different minimally invasive approaches for central thoracic cannulation. Porcine hearts were positioned in a plastic thoracic model. An endoscopic camera and multiple endoscopic instruments were used. Both access points, uniportal (lateral) and subxiphoidal, were simulatively investigated. A novel cannulation method using purse string sutures, a custom-made endoscopic puncture tool, guidewires, and dilator-assisted cannulas was developed. Simulations were tested in a closed circuit regarding leak tightness. The uniportal approach allowed a cannulation of the aorta, inferior vena cava, right atrium, and main pulmonary artery. Cannulation of the right branches of the pulmonary artery and vein was also possible. From the subxiphoid approach, cannulation of the aorta, main pulmonary artery, and both atria were possible. Subsequent evaluation and leakage tests revealed no damage to the surrounding structures and tightly sealed cannulation sites. The uniportal approach was also successfully performed in a human cadaver to connect the aorta and right atrium with cannulas from the subxiphoidal space. Both uniportal and subxiphoid central cannulation of potential sites for ECLS were feasible. This study encourages further investigation and potential clinical translation of minimally invasive central organ support.