Peripheral Intravenous Line Research Articles

Evaluating the Effectiveness of a Vascular Access Imaging Device Used in Training Recently Graduated Nurses

[abstFig src='/00290002/08.jpg' width='300' text='The VAID helps to select proper IV insertion sites' ] Peripheral intravenous (IV) line placement is one of the most invasive and painful procedures performed by nurses. Although it is a common nursing procedure, sufficient and effective skill training is necessary before nurses, especially new nurses, work with patients. Vascular access imaging devices (VAIDs) have been developed and put into use in hospitals. Many studies have been conducted to evaluate the effectiveness of the device in clinical settings such as in neonatal care, pediatric care, emergency care, etc., but the effectiveness of the device in training nurses who have just recently graduated has rarely been reported, especially in Japan. In this paper, we report on a quasi-experimental study that evaluated the effectiveness of the VAID for training recent nursing school graduates to successfully perform IV line placement. Eleven newly registered nurses participated in this study. Their preparations were video recorded for analysis. Students’<span class=”bold”>t</span>-tests were used to compare time and success rates of IV placement with VAID assistance and without it. Furthermore, subjects reported their feelings and the self-evaluation related to VAID use by answering a questionnaire, and their responses were analyzed. The results showed no significant change in the length of time needed nor in the success of peripheral IV line placement when the VAID was used; however, nurses indicated the VAID did help them in deciding where the IV should be inserted. These results suggest that the use of the VAID could be clinically meaningful as an IV training tool and that it could reduce the time needed to select venipuncture sites.

How Prepared Are Medical and Nursing Students to Identify Common Hazards in the Intensive Care Unit?

Care in the hospital is hazardous. Harm in the hospital may prolong hospitalization, increase suffering, result in death, and increase costs of care. Although the interprofessional team is critical to eliminating hazards that may result in adverse events to patients, professional students' formal education may not prepare them adequately for this role. To determine if medical and nursing students can identify hazards of hospitalization that could result in harm to patients and to detect differences between professions in the types of hazards identified. Mixed-methods observational study of graduating nursing (n = 51) and medical (n = 93) students who completed two "Room of Horrors" simulations to identify patient safety hazards. Qualitative analysis was used to extract themes from students' written hazard descriptions. Fisher's exact test was used to determine differences in frequency of hazards identified between groups. Identification of hazards by students was low: 66% did not identify missing personal protective equipment for a patient on contact isolation, and 58% did not identify a medication administration error (medication hanging for a patient with similar name). Interprofessional differences existed in how hazards were identified: medical students noted that restraints were not indicated (73 vs. 2%, P < 0.001), whereas nursing students noted that there was no order for the restraints (58.5 vs. 0%, P < 0.0001). Nursing students discovered more issues with malfunctioning or incorrectly used equipment than medical students. Teams performed better than individuals, especially for hazards in the second simulation that were similar to those in the first: need to replace a central line with erythema (73% teams identified) versus need to replace a peripheral intravenous line (10% individuals, P < 0.0001). Nevertheless, teams of students missed many intensive care unit-specific hazards: 54% failed to identify the presence of pressure ulcers; 85% did not notice high tidal volumes on the ventilator; and 90% did not identify the absence of missing spontaneous awakening/breathing trials and absent stress ulcer prophylaxis. Graduating nursing and medical students missed several hazards of hospitalization, especially those related to the intensive care unit. Orientation for residents and new nurses should include education on hospitalization hazards. Ideally, this orientation should be interprofessional to allow appreciation for each other's roles and responsibilities.

Is Tachycardia at Discharge From the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study

We evaluate the association between discharge tachycardia and (1) emergency department (ED) and urgent care revisit and (2) receipt of clinically important intervention at the revisit. The study included a nonconcurrent cohort of children aged 0 to younger than 19 years, discharged from 2pediatric EDs and 4 pediatric urgent care centers in 2013. The primary exposure was discharge tachycardia (last recorded pulse rate ≥99th percentile for age). The main outcome was ED or urgent care revisit within 72 hours of discharge. Additional outcomes included interventions received and disposition at the revisit, prevalence of discharge tachycardia at the index visit, and associations of pain, fever, and medications with discharge tachycardia. Multivariable logistic regression determined relative risk ratios for revisit and receipt of clinically important intervention at the revisit. Of eligible visits, 126,774 were included, of which 10,470 patients (8.3%) had discharge tachycardia. Discharge tachycardia was associated with an increased risk of revisit (adjusted RR 1.3; 95% confidence interval 1.2 to 1.5), increased risk of tachycardia at the revisit (relative risk 3.1; 95% confidence interval 2.6 to 3.7), and of the receipt of certain clinically important interventions (supplemental oxygen, respiratory medications and admission, antibiotics and admission, and peripheral intravenous line placement and admission). However, there was no increased risk for the composite outcome of receipt of any clinically important intervention or admission on revisit. Discharge tachycardia is associated with an increased risk of revisit. It is likely that tachycardia at discharge is not a critical factor associated with impending physiologic deterioration.

A study of the efficacy of stellate ganglion blocks in complex regional pain syndromes of the upper body.

Background and Aims:The effect of stellate ganglion blocks (SGBs) was examined in complex regional pain syndromes (CRPS) of the upper body.Material and Methods:A total of 287 SGB were given to patients with documented CRPS on medications. Spontaneous and provoked pain assessment was done with numeric pain rating scale (NPRS). The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and range of motion (ROM) was recorded before and after each blockade. Difference between a 15-point “global rating of change” scale determined the minimal clinically important difference of the DASH score.Results:The overall mean pain reduction was 73.2% (r = 0.83, P < 0.001) considering spontaneous and 55.8% (r = 0.77, P < 0.001) on provoked pain. Mean DASH score decreased from 53 (range 36–63; P = 0.14) to 10.4 (range 10–49.2; P = 0.005). The sensitivity to change was 6.9 for spontaneous and 4.9 for provoked pain. Increase in ipsilateral limb temperature has a good correlation with Horner's syndrome (HS) and sympathetic blockade. Minor, self-limiting complications, such as hoarseness, dysphagia, local hematoma, and ipsilateral brachial plexus block occurred in 11.5%. A rare complication of contralateral HS was documented. One patient developed a small pneumothorax, but it did not require intervention.Conclusions:SGB are relatively safe and effective management in patients with neuropathic conditions already on pharmacotherapy. Serial blocks attained an average reduction in pain by >3 NPRS points from the baseline for both spontaneous and provoked pain with a decrease in mean DASH score and improvement in ROM.

A Newborn with Multiple Anomalies

A late preterm neonate is born with an occipital encephalocele and other anomalies. ### Prenatal and Birth Histories ### Presentation The neurosurgery, otolaryngology, and neonatology departments were present at delivery. The encephalocele was large (Fig 1) and was initially placed in a sterile bag. Some spontaneous breaths were noted. Given the infant’s micrognathia, the otolaryngology team provided nasal intubation and placed the infant on positive pressure ventilation (Fig 2). The encephalocele was cleaned, wrapped in wet gauze, and placed in a polyethylene skin wrap by the neurosurgery team. The infant’s Apgar scores were 2, 6, and 8 at 1, 5, and 10 minutes, respectively. Before arrival at the NICU, a peripheral intravenous line was placed. The infant required 2 dextrose boluses to obtain a normal serum glucose value, and 1 normal saline fluid bolus to maintain appropriate blood pressure. She was then brought to the NICU and placed on assisted ventilation. …

Association between delivery methods for red blood cell transfusion and the risk of venous thromboembolism: a longitudinal study

Mechanisms of red blood cell delivery and their contribution to the incidence of venous thromboembolism are not well understood in the clinical setting. We assessed whether red blood cell transfusion through peripherally inserted central catheters (PICCs) affects the risk of venous thromboembolism compared with transfusion through non-PICC devices. We implemented a prospective study between Jan 1, 2013, and Sept 12, 2015, in patients (age ≥18 years) admitted to a general medicine ward or intensive care unit who received a PICC for any reason during clinical care in 47 hospitals in Michigan, USA, with a maximum follow-up of 70 days. The exposure of interest was route of red blood cell transfusion. The primary outcome was symptomatic, radiographically confirmed, deep-vein thrombosis in the arm or leg or pulmonary embolism. We used Cox proportional hazards regression for analyses. Venous thromboembolism developed in 482 (5%) of 10 604 patients with PICCs. Of 788 patients who received a red blood cell transfusion through a multi-lumen PICC, 61 had venous thromboembolism. The adjusted hazard ratio (HR) for venous thromboembolism in all patients whose transfusions were administered through a multi-lumen PICC was 1·96 (95% CI 1·47-2·61; p<0·0001) compared with patients not receiving a transfusion, and was 1·79 (1·09-2·95; p=0·022) compared with patients transfused through a peripheral intravenous line. Compared with delivery through a peripheral intravenous line, venous thromboembolism risk was not elevated if transfusions were delivered through a single-lumen PICC (HR 0·98, 95% CI 0·44-2·14; p=0·95) or central venous catheter (1·50, 0·77-2·91; p=0·23). For every red blood cell unit transfused through a PICC, there was a significantly increased risk of venous thromboembolism (adjusted HR 1·24, 95% CI 1·01-1·52; p=0·037). Patients who received a transfusion through a PICC in the left arm were significantly more likely to develop a deep-vein thrombosis in the ipsilateral arm compared with the contralateral side (HR 23·44, 95% CI 2·96-185·83; p=0·0028). Similarly, patients transfused through a right-sided PICC were more likely to develop deep-vein thrombosis in the ipsilateral arm (HR 3·37, 95% CI 1·02-11·14; p=0·047). Red blood cell delivery through a multi-lumen PICC is associated with a greater risk of thrombosis than transfusion through a peripheral intravenous catheter. Careful monitoring for venous thromboembolism when transfusing red blood cells through multi-lumen PICCs seems necessary. Blue Cross Blue Shield of Michigan and Blue Care Network, as part of the BCBSM Value Partnerships program.

Protected Clinical Indication of Peripheral Intravenous Lines: Successful Implementation

BackgroundA large, urban community hospital developed an insertion bundle to support the safe implementation of a policy of extended dwell time (clinical indication) for inpatient peripheral intravenous lines (PIVs). MethodsInternal evaluation of practices through direct observations as well as evidence-based guidelines and historic data on PIV-related bloodstream infections helped drive the bundle elements. A surveillance plan was in place to continue measurement of these outcomes during the postimplementation period. ResultsAt 12 months following implementation, the organization documented a 37% reduction (P = .03) in primary bacteremias (combining PIV and central line-associated bloodstream [CLABSI] infections) and a 19% percent reduction in PIV bloodstream infections. CLABSI rates were also reviewed, as 20% of CLABSI were noted to also have peripheral access present during the year prior to implementation. CLABSI standardized infection ratios for the publicly reported intensive care units decreased from 1.3 to 0.32 (P = .02). In addition, intravenous line start kit use decreased 48% during the year following bundle implementation. ConclusionsCareful planning and development of an education bundle and an insertion bundle in a community hospital setting allowed for longer dwell times and a trend of decreased bloodstream infections.

An Assessment Tool for the Placement of Ultrasound-Guided Peripheral Intravenous Access.

Background Ultrasound-guided peripheral intravenous line (USGPIV) placement is becoming an important tool in current clinical practice. Many residency programs utilize unstructured clinical observation to evaluate residents in this and other procedural skills. Simulation-based assessment permits educators to make objective, standardized observations, and may be ideal for assessment of important procedural competencies. Objective We created a simulation-based assessment tool for the skill of USGPIV placement. Methods A checklist tool was developed by a review of relevant literature and an expert review in accordance with established guidelines. Emergency medicine residents were recruited and surveyed on previous experience with USGPIV placement. Blinded, independent reviewers then utilized the checklist to assess residents as they made up to 3 attempts at USGPIV placement on a simulated pediatric arm. Results Of the 26 residents enrolled in our study, 26 participated (100%). A best attempt checklist score greater than or equal to 9 out of 10 correlated with expert performance (P < .001). Agreement between independent raters on first-attempt USGPIV placement score was determined by weighted kappa statistics to be 0.93 (95% CI 086-1.00). Conclusions The checklist assessment tool has acceptable interrater reliability and ability to distinguish performance at differing levels of competence. We propose this tool as a valuable component in the assessment of USGPIV access, and we hope this article serves as a roadmap for other educators to create similar assessment tools.

Peripheral Intravenous Line Placement and Utilization in an Academic Emergency Department

BackgroundRising health care costs and increased scrutiny concerning spending have prompted providers and hospitals to identify unnecessary procedures and waste. Peripheral intravenous line (pIV) placement is one of the most common medical procedures performed. A recent study reported that 50% of intravenous lines placed in the emergency department (ED) went unused. If half of all pIVs placed in EDs systemically go unused, the costs and complications associated with pIV placement are unacceptably high. ObjectivesOur study aims to ascertain the frequency of pIV placement and usage in an urban ED. MethodsThis was a retrospective review of medical records for consecutive patients seen in an academic ED in June 2014. The following data points were recorded: age, sex, chief complaint, acuity level on admission, pIV placement both prehospital and in the ED, and pIV utilization (for fluids, medications, or contrast administration). ResultsThere were 509 charts reviewed, with a median patient age of 40 years. Common chief complaint categories included neurologic, cardiac, and skin/soft tissue. Triage acuity was varied, with a mean of 3.3. A pIV was placed in 55% of subjects. Prehospital providers placed 19%. Of all pIVs placed, 72% were used for the administration of medications, 19% for contrast, and 67% for fluids. Eighty-five percent of pIVs were used; 51% of patients with a pIV were admitted from the ED. ConclusionIn this study's ED, 85% of pIVs were used prior to discharge. Strategies to lower pIV placement rates should focus on alternative routes of medication and fluid administration.

GENTAMICIN PHARMACOKINETIC VARIABILITY IS INFLUENCED BY CHOICE OF ADMINISTRATION ROUTE

IntroductionA critically ill neonate may have several routes of venous access available, operating at different flow rates and with different dead-volumes, and therefore with different delivery kinetics.AimsTo determine which lumen of a double lumen umbilical venous catheter (UVC) would be used for administration of intravenous gentamicin to a premature baby and what flush volume would be used.MethodsAn individual self-administered questionnaire was completed by Dunedin Hospital NICU nurses in April-May 2014. The questionnaire consisted of two scenarios describing babies of 24 and 32 weeks gestation, and asked that the site of administration be chosen on a diagram. Secondary information regarding flush volume was also collected and free-text responses encouraged.ResultsThere were 42 nurses employed in Dunedin NICU during this period, of whom 37 (88%) responded. For a 24-week gestation baby, 34 nurses (92%) would administer into the primary lumen (20ga), containing 10% dextrose (0.5 mL/hr), compared to 3 (8%) who would use the secondary lumen (23ga), containing parenteral nutrition fluid (2.1 mL/hr). For a 32-week gestation baby 35 nurses (95%) would administer through the slow-flowing primary lumen. If a peripheral intravenous line (PIV) was present this would be used preferentially by 35 nurses (95%) to reduce the risk of infection. Smaller flush volumes were documented following administration through the UVC compared with PIV (1.17–1.35 mL vs 2.4 mL at 24 weeks and 1.42–1.74 mL vs 3.2 mL at 32 weeks).DiscussionThe variability in intravenous delivery route may be a significant contributor to variability in neonatal gentamicin pharmacokinetics.

Ultrasound-Guided Peripheral IV Access in the Hands of Nurses' Aides

Multiple small studies since 2005 have shown that ultrasound guidance improves success of peripheral intravenous (IV) line placement when access is

Blood Samples of Peripheral Venous Catheter or The Usual Way: Do Infusion Fluid Alters the Biochemical Test Results?

Background:Most blood tests require venous blood samples. Puncturing the vein also causes pain, infection, or damage to the blood, and lymph flow, or long-term healing. This study aimed to determine and compare the biochemical laboratory value of the blood samples that were provided through: peripheral vein infusion (PVI) receiving continuous intravenous fluid; and the usual method of blood sampling.Methods:This is an interventional, quasi-experimental, and controlled study. The selected study sample included 60 patients, who were hospitalized during 2014, in the Internal Medicine, part of Martyrs of Persian Gulf, teaching hospital at Bushehr. Three blood samples were taken from each patient that were provided through PVI line (5 ml blood collected at beginning of IVC and then another 5 cc), and another case was prepared by common blood sampling (control). All the samples were analyzed in terms of sodium, potassium, urea and creatinine using SPSS Ver.19 software, by paired t-test and Pearson’s correlation coefficients.Results:There was a statistically significant difference between the amount of sodium and potassium in the first blood samples taken from the intravenous infusion line and vein puncture. However, no significant differences were found among the biochemical amount in the second blood samples taken from the intravenous infusion line and vein puncture.Conclusions:We can use blood samples taken from peripheral intravenous infusion lines after 5cc discarding from the first part of the sample for measuring the value of sodium, potassium, urea and creatinine.

Medical Adhesive-Related Skin Injury Prevalence Among Adult Acute Care Patients: A Single-Center Observational Study.

The purpose of this study was to measure the daily prevalence of adhesive product use and related skin injuries in adult patients in a non-intensive care unit setting. Prospective, descriptive study. The study sample consisted of patients cared for on 2 inpatient care units in a university-based acute care facility in the Midwestern United States. One was a 30-bed medical/surgical unit and the second was a 35-bed cardiac/telemetry unit. Their median age was 58 years; the average daily proportion of males and females was 56% and 42%, respectively. Medical adhesive-related skin injury (MARSI) prevalence was calculated using 3 methods: (1) the proportion of subjects who had any MARSI injury (subject prevalence), (2) the prevalence of MARSI by injury type and severity (severity prevalence), and (3) the proportion of medical adhesive products that had any associated MARSI (product prevalence). The daily subject prevalence of any MARSI injury ranged from 3.4% to 25.0% with a mean and median of 13.0% and 12.7%, respectively. The severity prevalence of MARSI injury ranged from 8 to 149 per 1000 product-days with a mean and median of 63 and 56 MARSIs per 1000 product-days, respectively. The median (range) product prevalence among all adhesive products varied from a high of 70 injuries per 1000 product-days for surgical closure to a low of 0 injuries per 1000 product-days for peripheral intravenous line dressing. Medical adhesive-related skin injury is a prevalent event in the acute care setting. Preventing skin injury has the potential to reduce complications, increase patient satisfaction, and improve clinical outcomes.

Comforting strategies and perceived barriers to pediatric pain management during IV line insertion procedure in Uganda's national referral hospital: A descriptive study.

BackgroundVenipuncture and intravenous (IV) cannula insertions are the two common sources of pain in hospitalized children and health care today. The WHO asserts that, pain relief is a basic fundamental right and requires a multidisciplinary approach. Nonpharmacological comforting strategies when implemented are important to relive pain related distress in children during peripheral IV line insertion. However, evidence to date that suggests implementation of such strategies and their barriers in Uganda remains very limited. This study aimed at establishing the current practices in regard to the use of comforting strategies and the perceived barriers faced by health care providers to implement pediatric pain management during IV line insertion procedure in Uganda’s national referral hospital, Mulago.MethodA cross sectional and descriptive study was conducted between December 1, 2012 and February 28, 2013 involving doctors, nurses and interns in six pediatric wards of Mulago Hospital in Uganda. A pre-tested self- administered and semi- structured questionnaire was used to collect the data. Data was entered into SPSS and descriptive statistics run on all the variables.ResultsOf the 120 questionnaires distributed, 105 (RR = 87.5 %) were returned and completed. The evidence based comforting strategies used for pain management during IV line insertion by the majority of health care professionals were; skin to skin (51 %) and appropriate upright positioning of the child on mother’s lap (69 %). The least used comforting strategies were; allowing the child to suck his thumb or hand (70 %), use of distraction (69 %) and directing the child to suck one of his fingers into his mouth (90 %). The identified barriers to implementing comforting strategies were; lack of time (42 %), having emergency situations (18 %), and not knowing the right method to use (11 %). Of 105, 100 (95 %) reported that there is need for continuous professional development on comforting strategies.ConclusionsFindings demonstrated that fewer health care providers used some evidence based comforting strategies of pain relief during pediatric peripheral IV line insertion. Distraction and other evidence based strategies for pain and distress relieve are less often used by the majority of the health care providers. Incorporating pediatric pain management content in all health professionals training curricula could improve the current practices for better health outcomes.

Simulation Training-a Necessity for Future Surgeons.

Simulation Training-a Necessity for Future Surgeons.

Safety of peripheral intravenous administration of vasoactive medication.

Central venous access is commonly performed to administer vasoactive medication. The administration of vasoactive medication via peripheral intravenous access is a potential method of reducing the need for central venous access. The aim of this study was to evaluate the safety of vasoactive medication administered through peripheral intravenous access. Over a 20-month period starting in September 2012, we monitored the use of vasoactive medication via peripheral intravenous access in an 18-bed medical intensive care unit. Norepinephrine, dopamine, and phenylephrine were all approved for use through peripheral intravenous access. A total of 734 patients (age 72 ± 15 years, male/female 398/336, SAPS II score 75 ± 15) received vasoactive medication via peripheral intravenous access 783 times. Vasoactive medication used was norepinephrine (n = 506), dopamine (n = 101), and phenylephrine (n = 176). The duration of vasoactive medication via peripheral intravenous access was 49 ± 22 hours. Extravasation of the peripheral intravenous access during administration of vasoactive medication occurred in 19 patients (2%) without any tissue injury following treatment, with local phentolamine injection and application of local nitroglycerin paste. There were 95 patients (13%) receiving vasoactive medication through peripheral intravenous access who eventually required central intravenous access. Administration of norepinephrine, dopamine, or phenylephrine by peripheral intravenous access was feasible and safe in this single-center medical intensive care unit. Extravasation from the peripheral intravenous line was uncommon, and phentolamine with nitroglycerin paste were effective in preventing local ischemic injury. Clinicians should not regard the use of vasoactive medication is an automatic indication for central venous access.

Utilization and Frequency of Peripheral Intravenous Lines Placed in an Emergency Department

Utilization and Frequency of Peripheral Intravenous Lines Placed in an Emergency Department

Lack of vincristine infiltrates in patients with retinoblastoma receiving chemotherapy by peripheral intravenous lines.

The delivery route of chemotherapy for intraocular retinoblastoma has become controversial. One objection to systemic delivery is the need for central venous access. We cross-referenced a hospital vascular access database with our tumor registry to determine the incidence of chemotherapy infiltrates. Sixty-five patients received 270 cycles of chemotherapy via peripheral intravenous access. Vincristine infiltration was 0% (95% confidence interval [CI] 0-0.16%) while that of non-vesicant chemotherapy was 0.7% (95%CI 0.1-2.6%). Giving chemotherapy via peripheral access to patients with retinoblastoma is safe. It can decrease therapy costs and prevent central line associated blood stream infections.

Sternal cleft: Anaesthetic management of a rare congenital anomaly.

Sir, A sternal cleft is a rare congenital anomaly resulting from the failure of fusion of lateral sternal bars during the 3rd month of intrauterine development.[1] It may be complete or incomplete (bifid type), depending on the degree of fusion of two lateral sternal bars, the latter being more common.[2,3] Associated anomalies, particularly cardiac anomalies, result in poor outcomes.[4,5] The surgical procedure is associated with critical changes in haemodynamics and cardiopulmonary mechanics, necessitating invasive monitoring, preparedness for cardiopulmonary bypass and resuscitation (CPR).[6] Here, we report anaesthetic management of a case of sternal cleft repair with a brief review of available literature. A full-term male baby, weighing 2.6 kg, was delivered by caesarean section. The attending paediatrician noted a longitudinal depression at the sternal region which was more evident during inspiration [Figure 1]. Pulsation of great vessels was easily seen through the defect which was covered by a thin layer of skin. Two parallel and completely separated sternal bars were palpated along the depression. There was no anterior abdominal wall defect, diastasis of recti, fascial haemangioma, atrophic skin or paradoxical movement of the thoracic cage. A provisional diagnosis of isolated sternal cleft was made, and the baby was evaluated for associated anomalies. Chest X-ray revealed normal lung fields with a wide gap between the medial ends of the clavicles [Figure 2]. Echocardiogram and blood investigations were normal. The child was posted for sternal cleft repair on the 3rd postpartum day. In the operating room, standard monitoring was attached. The pulse rate was 130/min, oxygen saturation 97% with oxygen (O2) supplementation by nasal cannula at 3L/min and respiratory rate was 34/min. The child was induced with inhalation of sevoflurane (2 to 8%) in O2 and two peripheral intravenous lines were secured. The injections of fentanyl (5μg) and atracurium (1.5mg) were administered, and trachea was intubated with 3.5mm uncuffed endotracheal tube. The right radial artery was cannulated for invasive blood pressure monitoring. Anaesthesia was maintained with isoflurane in O2 /air (40–60) mixture. The child was put on pressure controlled ventilation, and adequate tidal volume (VT) was achieved with peak inspiratory pressures (PIP) of 18 mmHg. A vertical midline incision from the suprasternal notch to xiphoid process was given by the surgeons, and margins of sternal bars were freshened, followed by closure of the defect. The blood loss was minimal. PIP and haemodynamics were observed for next 10 min before knotting the sutures. PIP of 20 mmHg was required to achieve the same VT with no significant changes in haemodynamics. On the 2nd postoperative day, the trachea was extubated, and the child was discharged home in stable condition on the 7th day. Figure 1 Obvious midline depression in the child Figure 2 Wide gap between the medial ends of the clavicles The reported incidence of sternal cleft varies across the institutes. Acastello et al.[7] noted an incidence of 0.15% of all chest deformities during a 25 years period observation. It is usually diagnosed at birth due to the presence of cosmetic deformity and is generally asymptomatic. Associated cardiac anomalies, defects in the anterior chest wall (ectopia cordis), or the presence of Cantrell's Pentalogy (defects involving the abdominal wall, sternum, diaphragm, pericardium and heart) indicate poor prognosis.[4,5] Surgical correction is required to restore bony protection to the vital organs and great blood vessels, to provide normal intra-thoracic pressure-volume relationships and to eliminate paradoxical movement of the thoracic viscera.[1,2,3] Surgery is preferred in the new born period as the thoracic cage is more compliant, and the closure of the chest wall can easily accommodate the thoracic viscera without compressing the underlying structures.[6] It presents distinct challenges to the anaesthesiologist due to the potential involvement of multiple organ systems and the risk of direct injury to the vital organs. Associated complex congenital heart disease or poor baseline cardiac functions warrant standby cardiopulmonary bypass.[4,5,6] Arterial and central venous pressure monitoring is useful, as is trans-oesophageal echocardiography (TEE). Intraoperative TEE offers real-time information on volume status and cardiac output. The repair may lead to compression on the intra-thoracic organs which may cause haemodynamic instability and decreased lung compliance necessitating invasive monitoring, and close observation of ventilatory parameters. Rapid blood loss, arrhythmias, cardiac dysfunction and pneumothorax are the possible complications.[2,3] Literature advises test closure for 5–10 min while observing the haemodynamics and cardiopulmonary interactions.[3] To conclude, repair of sternal cleft requires invasive haemodynamic monitoring, close observation of ventilatory parameters and preparedness for CPR. Elective postoperative mechanical ventilation with adequate analgesia helps in early recovery.

Anesthesia and the Fetus

Anesthesia and the Fetus