Extravasation Rate Research Articles

Application of Key Indicators of Tumor Internal Medicine Quality Evaluation in continuous improvement of specialized nursing quality

Objective To explore the application effect of key indicators of oncology nursing quality evaluation in the continuous improvement of specialist nursing quality. Methods The Delphi method was used to cons-truct 14 key indicators of oncology nursing quality evaluation, and the key indicators were used to control the quality of specialist nursing in the tumor area. Data were collected and a database was established. Based on the data, the quality of the nursing care and continuous quality improvement were carried out. Results The results of the data from the first year (before the intervention in 2016) and the second year (after the intervention in 2017) were compared with the data of the key indicators of the quality evaluation of the specialist nursing. The results showed that the indicators had different degrees of decline. The data before and after intervention were: chemotherapy drug extravasation rate 0.20% (33/16 861) and 0.10% (20/19 957), and the incidence of severe pain was 1.65% (1 747/106 114) and 1.43% (1 521/106 462). The incidence of anxiety was 2.17% (2 305/106 114) and 1.53% (1 633/106 462), and the incidence of depression was 2.27% (2 408/106 114) and 1.28% (1 359/106 462). The difference was statistically significant (χ2=5.80-300.90, P<0.05); The other 9 indicators of process have improved to varying degrees. Conclusions 14 key indicators of oncology nursing quality evaluation are applied to the oncology ward for specialized nursing quality management and quality improvement, which can monitor the quality of key specialist nursing in real time and dynamically. It can accurately select clinical nursing priority improvement projects and improve specialist nursing. Quality; energy evaluation to improve the quality of specialist nursing quality; help improve the quality management of specialist nursing and ensure patient safety. Key words: Nursing; Quality indicators; Oncology; Clinical application

A 3D microvascular network model to study the impact of hypoxia on the extravasation potential of breast cell lines

Hypoxia is a common feature of the tumor microenvironment. Accumulating evidence has demonstrated hypoxia to be an important trigger of tumor cell invasion or metastasizes via hypoxia-signaling cascades, including hypoxia-inducible factors (HIFs). Microfluidic model can be a reliable in vitro tool for systematically interrogating individual factors and their accompanying downstream effects, which may otherwise be difficult to study in complex tumor tissues. Here, we used an in vitro model of microvascular networks in a microfluidic chip to measure the extravasation potential of breast cell lines subjected to different oxygen conditions. Through the use of HIF-1α knock-down cell lines, we also validated the importance of HIF-1α in the transmigration ability of human breast cell lines. Three human breast cell lines derived from human breast tissues (MCF10A, MCF-7 and MDA-MB-231) were used in this study to evaluate the role of hypoxia in promoting metastasis at different stages of cancer progression. Under hypoxic conditions, HIF-1α protein level was increased, and coincided with changes in cell morphology, viability and an elevated metastatic potential. These changes were accompanied by an increase in the rate of extravasation compared to normoxia (21% O2). siRNA knockdown of HIF-1α in hypoxic tumors significantly decreased the extravasation rates of all the cell lines tested and may have an effect on the function of metastatic and apoptotic-related cellular processes.

In vitro pharmacokinetic phantom for two-compartment modeling in DCE-MRI

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is an established minimally-invasive method for assessment of extravascular leakage, hemodynamics, and tissue viability. However, differences in acquisition protocols, variety of pharmacokinetic models, and uncertainty on physical sources of MR signal hamper the reliability and widespread use of DCE-MRI in clinical practice. Measurements performed in a controlled in vitro setup could be used as a basis for standardization of the acquisition procedure, as well as objective evaluation and comparison of pharmacokinetic models. In this paper, we present a novel flow phantom that mimics a two-compartmental (blood plasma and extravascular extracellular space/EES) vascular bed, enabling systemic validation of acquisition protocols. The phantom consisted of a hemodialysis filter with two compartments, separated by hollow fiber membranes. The aim of this phantom was to vary the extravasation rate by adjusting the flow in the two compartments. Contrast agent transport kinetics within the phantom was interpreted using two-compartmental pharmacokinetic models. Boluses of gadolinium-based contrast-agent were injected in a tube network connected to the hollow fiber phantom; time-intensity curves (TICs) were obtained from image series, acquired using a T1-weighted DCE-MRI sequence. Under the assumption of a linear dilution system, the TICs obtained from the input and output of the system were then analyzed by a system identification approach to estimate the trans-membrane extravasation rates in different flow conditions. To this end, model-based deconvolution was employed to determine (identify) the impulse response of the investigated dilution system. The flow rates in the EES compartment significantly and consistently influenced the estimated extravasation rates, in line with the expected trends based on simulation results. The proposed phantom can therefore be used to model a two-compartmental vascular bed and can be employed to test and optimize DCE-MRI acquisition sequences in order to determine a standardized acquisition procedure leading to consistent quantification results.

SAFETY OF PERIPHERAL INTRAVENOUS ADMINISTRATION OF VASOACTIVE MEDICATION: A RETROSPECTIVE ONE YEAR FOLLOW UP

SESSION TITLE: Critical Care 2 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Central venous access is commonly performed to administer vasoactive medications. Our group previously studied the safety of vasoactive medications administered through peripheral intravenous (PIV) access after implementing a safety protocol. We have been using this protocol now for over two years. Here, we performed a follow-up study confirming the safety and assessing the complications of vasoactive medications administered through a PIV. METHODS: Retrospective chart review was performed over a 1-year period (06/2014-06/2015) following the conclusion of the previous study. We monitored the use of norepinephrine, phenylephrine and dopamine through a PIV with a standard safety protocol in place. Basic demographic data, Simplified Acute Physiology Score (SAPS)-II scores and outcomes were evaluated. We assessed rates of extravasation of peripheral vasoactive medications and associated complications. RESULTS: A total of 435 patients required vasoactive medications during their MICU stay over this time period. 306 patients received vasoactive medications through a PIV. The average age of patients receiving vasoactive medications through a PIV was 66.8 ±18.4 with male predominance (58.2%). Mean SAPS-II score for these patients was 59.7±18.7. 64.1% of patients required mechanical ventilation (MV) and 19.6% required hemodialysis (HD). MICU mortality for patients with PIV was 31.4% compared to 53.5% with central venous catheter (CVC). Vasoactive medications used were norepinephrine (n=213), dopamine (n=8) and phenylephrine (n=85). Average duration of vasoactive medication via PIV was 49.0 hours (SD: 52), which was similar to our original study (49±22 hours). Extravasation of vasoactive medication via PIV occurred in 6 patients (2%) without any tissue injury following prompt recognition and treatment with local phentolamine/terbutaline and local nitroglycerin. There were 31 (10.1%) patients receiving vasoactive medications through a PIV who eventually required a central venous catheter (CVC). Indication for switching to a CVC was extravasation (3.2%), high-dose (19.4%), multiple-pressors (51.6%) and loss of PIV access (25.8%). CONCLUSIONS: Safety of vasoactive medication use through a PIV was again validated at our tertiary center MICU, subsequent to our pilot study. Extravasation was uncommon (2%), and if it occurred, the use of a standard protocol (phentolamine/terbutaline/nitroglycerin) was successful in preventing local tissue ischemia. The use of PIV prevented the need for a CVC in 70% of our patients without any significant increase in complications. Therefore, intensivists should not regard the use of vasoactive medications as an automatic indication for CVC. CLINICAL IMPLICATIONS: Use of PIV for vasoactive medication administration reduces the use of CVC, and thus represents potential for risk reduction in the MICU. DISCLOSURES: No relevant relationships by Abhinav Agrawal, source=Web Response No relevant relationships by Anna Chang, source=Web Response No relevant relationships by Zubair Hasan, source=Web Response No relevant relationships by Seth Koenig, source=Web Response No relevant relationships by Maksim Korotun, source=Web Response No relevant relationships by Paul Mayo, source=Web Response No relevant relationships by Aleksandr Melamud, source=Web Response No relevant relationships by Mangala Narasimhan, source=Web Response

Elective replacement of intravenous cannula in neonates-a randomised trial.

Peripheral intravenous cannula (PIVC) insertion is one of the most common invasive procedures performed in neonates and is frequently associated with adverse events. There are no studies in the neonatal population looking at the possibility of reducing the risk of PIVC-related complications by elective replacement of PIVC. A randomised, non-blinded, control trial was conducted in a tertiary level neonatal unit in Melbourne, Australia, to examine rates of extravasation in neonates with elective replacement of PIVC as compared to standard practice. Neonates born at 32weeks of gestation or more were randomly assigned to have their PIVC replaced electively (every 72-96h) or when clinically indicated in a 1:1 allocation ratio after parental consent. Primary outcome studied was rate of extravasation. Secondary outcomes included rates of phlebitis, leakage or spontaneous dislodgement of PIVC. One hundred thirteen infants were enrolled. Extravasation was noted in 33 (60%) of standard practice group vs. 28 (48.3%) of elective replacement (RR 0.80, CI 0.57-1.13, p = 0.21) infants. Time to first extravasation was similar between the groups (hazard ratio 0.69, CI 0.42-1.15). Extravasation events per 1000 IV hours were also similar between groups. Similar results were seen by both intention to treat and per protocol analyses. There was an increase in leaking rates (HR1.98, CI 1.03-3.81, p = 0.04) in the elective group, while phlebitis and spontaneous dislodgement rates were similar to standard group.Conclusion: Elective replacement of PIVC in neonates is not associated with reduction in extravasation rates.Trial registration: This trial has been registered with the Australian and New Zealand Clinical Trials Register. Identifier: ACTRN12615000827538. What is Known: • The reported incidence of extravasation injury is as high as 70% in the neonatal and paediatric population and has an association with cannula dwell time. • Adult studies have done to look at the possibility of reducing intravenous cannula-related complications with routine replacement of the cannulas but no similar studies have been done in the neonatal population. What is New: • Routine replacement of intravenous cannula in neonates between 72 and 96h of use does not reduce the rate of extravasation injuries. • There might be some added complications associated with such a practice.

Extravasation of Brownian Spheroidal Nanoparticles through Vascular Pores

In modern cancer treatment, there is significant interest in studying the use of drug molecules either directly injected into the bloodstream or delivered by nanoparticle (NP) carriers of various shapes and sizes. During treatment, these carriers may extravasate through pores in the tumor vasculature that form during angiogenesis. We provide an analytical, computational, and experimental examination of the extravasation of point particles (e.g., drug molecules) and finite-sized spheroidal particles. We study the advection-diffusion process in a model microvasculature, consisting of a shear flow over and a pressure-driven suction flow into a circular pore in a flat surface. For point particles, we provide an analytical formula S(κ,P,Q)≈(1/κ+π/(4(1+0.3959P1/2)2/3))−1+2PQ for the dimensionless Sherwood number S, i.e., the extravasation rate, in terms of the pore entry resistance (Damköhler number κ), the shear rate (Péclet number P), and the suction flow rate (suction strength Q). Brownian dynamics (BD) simulations verify this result, and our simulations are then extended to include finite-sized NPs, in which no analytical solutions are available. BD simulations indicate that particles of different geometries have drastically different extravasation rates in different flow conditions. In general, extreme aspect ratio particles provide a greater flux through the pore because of favorable alignment with streamlines entering the pore and less hindered interaction with the pore. We validate the BD simulations by measuring the in vitro transport of both bacteriophage MS2 (a spherical NP) and free dye (a model drug molecule) across a porous membrane. Despite their vastly different sizes, BD predicts S = 8.53 E−4 and S = 27.6 E−4, and our experiments agree favorably, with Sexp=10.6 E−4± 1.75 E−4 and Sexp=16.3 E−4 ± 3.09 E−4, for MS2 and free dye, respectively, thus demonstrating the practical utility of our simulation framework.

Contrast-enhanced CT for Colonic Diverticular Bleeding before Colonoscopy: A Prospective Multicenter Study

Purpose To demonstrate the usefulness of precolonoscopy intravenous contrast material-enhanced CT for colonic diverticular bleeding (CDB). Materials and Methods A prospective, multicenter, observational study was performed. Patients with acute-onset hematochezia who were admitted to hospital were included, and those without CDB were excluded. CT was performed before colonoscopy. A Mann-Whitney U test, χ2 test, and multivariable logistic regression analysis were performed to determine the accuracy of CT before colonoscopy. Results A total of 442 patients (mean age, 71.2 years; 302 male patients; 68.3% men) were included between January 2014 and December 2015, and 202 patients were diagnosed as having CDB. The positive extravasation rate during CT was 50 of 202 (24.7%) among all patients and five of nine (55.6%) among patients who underwent CT within 1 hour of the last hematochezia. At multivariable analysis, the interval from the last hematochezia until CT was a predictor of extravasation (beta coefficient, -.0038 ± 0.0014 [standard deviation]). Extravasation at CT had a sensitivity of 38 of 66 (57.6%; 95% confidence interval: 44.8%, 69.7%) and a specificity of 124 of 136 (91.2%; 95% confidence interval: 85.1%, 95.4%) for the prediction of stigmata of recent hemorrhage of diverticula during colonoscopy. The sensitivity was higher in patients who underwent CT examination within 4 hours of hematochezia, compared with those examined after 4 hours (64.7% [33 of 51] vs 33.3% [five of 15]; P < .01). Conclusion Extravasation findings for CT with intravenous contrast material had high specificity for the prediction of stigmata of recent hemorrhage of diverticula during colonoscopy, regardless of the timing of the CT examination. Although the sensitivity was relatively low, it was higher when the CT examination was performed within 4 hours after the last hematochezia. Therefore, urgent precolonoscopy CT may contribute to decision making regarding whether an urgent colonoscopy should be performed.

Tuning Enzymatically Crosslinked Silk Fibroin Hydrogel Properties for the Development of a Colorectal Cancer Extravasation 3D Model on a Chip.

Microfluidic devices are now the most promising tool to mimic in vivo like scenarios such as tumorigenesis and metastasis due to its ability to more closely mimic cell's natural microenvironment (such as 3D environment and continuous perfusion of nutrients). In this study, the ability of 2% and 3% enzymatically crosslinked silk fibroin hydrogels with different mechanical properties are tested in terms of colorectal cancer cell migration, under different microenvironments in a 3D dynamic model. Matrigel is used as control. Moreover, a comprehensive comparison between the traditional Boyden chamber assay and the 3D dynamic microfluidic model in terms of colorectal cancer cell migration is presented. The results show profound differences between the two used biomaterials and the two migration models, which are explored in terms of mechanical properties of the hydrogels as well as the intrinsic characteristics of the models. Moreover, the developed 3D dynamic model is validated by demonstrating that hVCAM‐1 plays a major role in the extravasation process, influencing extravasation rate and traveled distance. Furthermore, the developed model enables precise visualization of cancer cell migration within a 3D matrix in response to microenvironmental cues, shedding light on the importance of biophysical properties in cell behavior.

Incidence of urinary extravasation and rate of ureteral stenting after high-grade renal trauma in adults: a meta-analysis.

BackgroundCollecting system injury and urinary extravasation is an important yet understudied aspect of renal trauma. We aimed to examine the incidence of urinary extravasation and also the rates of ureteral stenting after high-grade renal trauma (HGRT) in adults.MethodsA search strategy was developed to search Ovid Medline, Embase, CINAHL, and Cochrane Library. Two reviewers screened titles and abstracts, followed by full-text review of the relevant publications. Studies were included if they indicated the number of patients with HGRT [the American Association for the Surgery of Trauma (AAST) grades III–IV or equivalents] and number of patients with urinary extravasation. A descriptive meta-analysis of binary proportions was performed with random-effects model to calculate the incidence of urinary extravasation and rates of ureteral stenting.ResultsAfter screening, 24 and 20 studies were included for calculating urinary extravasation and stenting rates, respectively. Most studies involved blunt injury and were retrospective single-center case series. Incidence of urinary extravasation was 29% (95% CI: 17–42%) after HGRT (grade III–V), and 51% (95% CI: 38–64%) when only grade IV–V injuries were combined. Overall, 29% (95% CI: 22–36%) of patients with urinary extravasation underwent ureteral stenting.ConclusionsApproximately 30% of patients with HGRT are diagnosed with urinary extravasation and 29% of those with urinary extravasation undergo ureteral stenting. Understanding the rate of urinary extravasation and interventions is the first step in creating a prospective trial designed to demonstrate when ureteral stenting and aggressive management of urinary extravasation is needed.

The Effect of Sphingosine 1‐Phosphate on Endothelial Permeability Is Fluid Flow Dependent

Blood vessel permeability is mediated by the remodeling of endothelial cells (EC) that are connected by specialized junctional complexes. Sphingosine‐1‐phosphate (S1P), a bioactive lipid molecule localized in the blood plasma, has been implicated in regulating endothelial barrier function1, and the biological effect of S1P has been shown to be flow‐dependent. For example, application of laminar shear stress (LSS) upregulates the expression of S1P receptor 1 (S1PR1). However, the role of fluid forces that arise at vessel bifurcations in regulating the effect of S1P remains unclear. To address this gap in knowledge, we developed a novel microfluidic model of a bifurcating vessel (MBV) that reproduces the main fluid forces present in the branching microvasculature, i.e. bifurcating fluid flow (BFF) applied normal and LSS applied tangential on the ECs, to study endothelial hydraulic conductivity (Lp) in response to applied S1P and selective inhibition of S1P receptors 1 and 2 (S1PR2).The MBV consists of a 1300 μm wide inlet microchannel that bifurcates to two 500 μm wide daughter microchannels (Fig. 1A). In addition, the microdevice includes a central compartment filled with a collagen type I solution that recapitulates the perivascular extracellular matrix (ECM). Polydimethylsiloxane soft lithography was used to fabricate MBV with monolithic features 50 μm in height. The microchannels were lined with human umbilical endothelial cells (HUVECs) (Fig. 1B), and flow rates were controlled with a syringe pump. W123 (10 μM) and JTE‐013 (200 nM) were used to pharmacologically inhibit S1PR1 and S1PR2, respectively. The extravasation rate of 10 kDa FITC‐conjugated Dextran as a fluorescent tracer was quantified to measure Lp under each condition.Treatment with 500 nM S1P for 6 h under static condition caused a ~7‐fold increase in Lp (Fig.2A). In contrast, treatment with 500 nM S1P after inhibiting S1PR2 with JTE‐013 decreased Lp by ~5‐fold, suggesting that S1PR2 functions to destabilize endothelial barrier function. Interestingly, treatment with 500 nM S1P after inhibition of S1PR1 did not elicit a change in Lp suggesting that functioning S1PR1 is necessary to induce an increase in Lp by S1P (Fig.2A). Application of 500 nM S1P alongside BFF, which is characterized by stagnated fluid flow at the base of the bifurcation point and LSS (~3 dyn/cm2) in the downstream branched vessels decreased Lp by 45% and 52%, respectively, compared to static control condition (Fig.2B). Interestingly, the application of BFF and LSS in absence of S1P elicited similar responses to the case where S1P was present during perfusion (Fig.2B), suggesting a stabilizing role for BFF and LSS independent of S1P.We developed an in vitro microfluidic model of a branching vessel that enables accurate and quantitative measurements of Lp under the effect of S1P and fluid flow stimuli. The findings from this study can lead to the development of novel therapeutic strategies to restore dysregulated vascular barrier.Support or Funding InformationFunding was provided by the American Heart Association, and the American Cancer Society.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Younger age and in situ duration of peripheral intravenous catheters were risk factors for extravasation in a retrospective paediatric study.

Epidemiological data on the incidence and risk factors of extravasation of peripheral intravenous catheters (PIVC) in neonates and children are scarce and that is what this study explored. This was a one-year retrospective study of all neonates and paediatric intensive care patients with at least one recorded PIVC at the Geneva University Hospitals, Switzerland, in 2013. The extravasation rate was determined for all patients, including neonates below 28 days, and for all PIVCs. Multivariate analysis of the associated risk factors was performed. We analysed 1300 PIVC in 695 paediatric patients with a median age of 1.5 years. The overall extravasation incidence was 17.6% for all patients and 11.7% for PIVC. The overall incidence rate of PIVC extravasation was 4.5 per 100 catheters days, and the risk was highest in the 201 neonates, at 28.4%. The incidence rate four days after insertion of the PIVC was around three times higher than on day one. Neonates and the in situ duration of PIVCs were associated risk factors (p < 0.001). Extravasation was frequent and neonates were particularly at risk. Younger age and longer in situ PIVC duration were independent risk factors for extravasation.

Effects of Hypoxia on Breast Cancer Extravasation in a 3D Microvascular Network

Hypoxia within the tumor microenvironment plays an important role in regulating breast cancer progression and is associated with metastasis and patient mortality. Lack of oxygen in the tissue triggers changes in gene expression mediated by hypoxia-regulated proteins, i.e. hypoxia inducible factors (HIFs) that impact cancer in numerous ways: angiogenesis, metabolic reprogramming, epithelial-mesenchymal transition (EMT), invasion, and metastasis. Recent advances in microfabrication technologies have allowed for the development of in vitro platforms that recapitulate cellular components and functions relevant to cancer metastasis. Previously, we engineered 3D vascular networks with human umbilical endothelial cells (HUVECs) seeded in fibrin gels and cultured to allow signaling with human lung fibroblasts (HLFs). HUVECs spontaneously formed networks within 24 hours and the engineered perfusable vessels were mature and perfusable after 4 days. Despite the importance of hypoxia in tumour progression, as well as advances in modeling angiogenesis and vasculogenesis, these models have not previously been used to study hypoxia in metastatic tumours. Also, most pathology and gene-expression studies are performed on primary tumours, and little is known about hypoxia at the metastatic site. We, therefore, sought to investigate how hypoxia affects cancer metastasis from in vitro blood vessels. In this study, we show that three breast cancer cell lines cultured in normoxia, hypoxia, and with knock-down HIF hypoxia cells, exhibit changes in extravasation rates 6 hours after perfusion into the networks. Hypoxia is shown to activate genetic programs that facilitate cell survival, while at the same time, promoting invasion and metastasis. Continuing studies will examine mechanisms mediating the role of hypoxia in metastasis, and these may lead to new and innovative therapeutic strategies to limit metastatic disease.

Learning curves of two different techniques for the intra-articular injection of the knee joint under fluoroscopic guidance

The aim of the study was to compare the learning curves of three beginner operators using two different techniques of intra-articular injection of the knee under fluoroscopic guidance with a superolateral approach. In total, 177 consecutive patients (72 females (40.7%) and 105 males (59.3%), mean age 42.2±15.0years) scheduled for a computed tomography (CT) arthrography and without joint effusion on the lateral X-rays were enrolled. They underwent an intra-articular injection of the knee under fluoroscopic guidance with a superolateral approach. Patients were randomly assigned to three different operators, including a junior supervisor and two first-year residents in radiology who never performed an intra-articular injection of the knee before the present study. Procedures in lateral or supine position were randomly assigned tothree operators. There was a higher rate of successful injections with the lateral position (92.1%) than with supine position (80.2%) (odds ratio (OR) 4.52, 95% confidence interval (CI) 1.46-14.0). A significant learning effect was observed for the supine position, while none was observed for the lateral position. Pain and time of fluoroscopy did not differ between the two procedures (p=0.85 and p=0.10, respectively). Junior supervisor had a higher rate of successful intra-articular injection compared with the other two operators (p=0.0072). There was a statistically significant higher rate of extravasation with the supine position (66.3%) than with lateral position (19.7%) (p<0.0001, OR 0.13, 95% CI 0.06-0.25). The intra-articular injection of the knee under fluoroscopic guidance with the patient in lateral position is an easy technique for operators in training with a low rate of extravasation. Lateral position does not require a supplementary irradiation and does not increase the procedural pain. Personal operator's skill is an independent factor in determining the success of the training.

Predictors of active arterial hemorrhage on angiography in pelvic fracture patients.

To determine predictors of active angiographic hemorrhage in pelvic fracture patients. This retrospective study included 66 trauma patients who had major hemorrhages due to pelvic fractures, and who underwent pelvic angiography between January 2012 and December 2014. The study population comprised 31 males and 35 females (mean age 44.2±20.7years). The main outcome was active hemorrhage on pelvic angiography. Clinical and imaging variables including demographics, hemodynamic parameters, injury severity, types of pelvic fracture, laboratory data, blood transfusions and CT findings were analyzed. Multivariate logistic regression was used to identify predictors of active angiographic hemorrhage. Of the 66 study patients included, 41 patients had active angiographic hemorrhage. These patients had more blood transfusions, higher activated partial thromboplastin times and higher rates of contrast extravasation on CT (p<0.05). Three independent predictors of active angiographic hemorrhage were identified, including contrast extravasation on CT (OR: 74.6, p<0.001), more than 8 units of RBC transfusions (OR: 12.5, p=0.018) and ISS ≥ 16 (OR: 11.1, p=0.029). Contrast extravasation on CT, high volume RBC transfusions and ISS ≥ 16 can help us to select pelvic fracture patients for angiography more precisely.

Influence of parameter accuracy on pharmacokinetic analysis of hyperpolarized pyruvate.

To explore the effects of noise and error on kinetic analyses of tumor metabolism using hyperpolarized [1-13 C] pyruvate. Numerical simulations were performed to systematically investigate the effects of noise, the number of unknowns, and error in kinetic parameter estimates on kinetic analysis of the apparent rate of chemical conversion from hyperpolarized pyruvate to lactate (kPL ). A pharmacokinetic model with two physical and two chemical pools of hyperpolarized spins was used to generate and analyze the synthetic data. The reproducibility of kPL estimates worsened quickly when peak signal-to-noise ratio for hyperpolarized pyruvate was below approximately 20. The accuracy of kPL estimates was most sensitive to errors in high excitation angles, the vascular blood volume fraction (vb ), and the rate of pyruvate extravasation (kve ), and was least sensitive to errors in the T1 of pyruvate. When vb and/or kve were fit as additional unknowns, the accuracy of kPL estimates suffered, and when the vascular input function of pyruvate was also fit, the reproducibility of kPL estimates worsened. The accuracy and precision of kPL estimates improve substantially for peak signal-to-noise ratio above approximately 20. Accurate estimates of perfusion parameters (combinations of vb , kve , and the pyruvate vascular input function) and transmit calibration at high excitation angles have the greatest effect on the accuracy of kinetic analyses. Magn Reson Med 79:3239-3248, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Interrupted versus continuous suturing for vesicourethral anastomosis during radical prostatectomy: protocol for a systematic review and meta-analysis

IntroductionRadical prostatectomy is the mainstay of treatment for prostate cancer. The vesicourethral anastomosis is a critical step, which most likely impacts urinary continence and urethral stenosis. To date, it still...

Clinical outcome and subsequent sequelae of cement extravasation after percutaneous kyphoplasty and vertebroplasty: a comparative review.

Background Injection of cement during vertebroplasty and kyphoplasty can leak into surrounding structures and could be symptomatic. Purpose To identify the sites and incidence of cement extravasation after kyphoplasty and vertebroplasty, and to evaluate their impacts on clinical outcomes. Material and Methods A retrospective review of 316 patients treated with kyphoplasty and vertebroplasty; 411 cases were included (223 kyphoplasty and 188 vertebroplasty). Cement extravasation was evaluated postoperatively by computed tomography (CT) scan of the spine. Clinical outcomes were assessed by visual analog scale (VAS) and Oswestry Disability Index (ODI). Results There was a statistically significant difference in the incidence rate of cement extravasation between vertebroplasty and kyphoplasty groups ( P < 0.04). The most common site of cement extravasation was in paravertebral soft tissues for vertebroplasty (n = 33, 40.7%) and for kyphoplasty (n = 30, 30%). In the subgroup where cement leaked into the intradiscal space, adjacent vertebral body fractures occurred in 3/26 vertebrae (11.5%) in the vertebroplasty group and in 2/18 vertebrae (11.1%) in the kyphoplasty group. Both groups showed a statistically significant decrease in both VAS ( P < 0.001) and ODI scores ( P < 0.001). There was no significantly difference in patient satisfaction between those who had cement extravasation and those who did not, in both groups. Conclusion Kyphoplasty has an advantage in terms of less risk of cement extravasation. However, this factor did not reflect on subsequent sequelae or final clinical outcomes. This study did not find a distinct correlation between intradiscal cement extravasation and increased risk of adjacent vertebral fractures.

339 Comparison of Intravenous Contrast Extravasation Rates from Peripheral IVs Placed by Registered Nurses Using Ultrasound Guidance Versus Standard Methods

Placement of ultrasound-guided peripheral IVs (USGIV) is common practice in many emergency departments; many of these are used for administration of IV contrast for computed tomography (CT) examinations. A single prior study found the contrast extravasation (CE) rate amongst USGIVs placed by physicians to be greater than those placed using standard methods (3.6 vs 0.3%). Many emergency departments (EDs) have registered nurses (RNs) who have been trained in the placement of USGIVs, but whether these perform as well as those placed by physicians is unknown. The primary outcome of this study is comparison of the CE events between USGIVs placed by RNs and those placed using standard technique. Secondary outcomes include assessment of the associations between IV characteristics (location, size, length) and patient factors and CE in patients with USGIVs. This was a retrospective chart review, performed at an urban tertiary care facility with an annual ED volume of 65,000. Our ED has a nursing-lead program that trains RNs to place USGIVs (2.5in 18g or 1.75in 20g). All USGIVs placed by RNs are logged for quality-assurance purposes. We queried our electronic patient safety incident reporting system for all CE events (mandatory reporting is required by our hospital system) between May 2014, and February 2017, during which time the USGIV program was operational. The medical record for each extravasation event was reviewed, and data on patient and IV characteristics were recorded. During the study period, 1,500 USGIVs were placed by 27 RNs. Contrast was administered 29,508 times, 291 via USGIVs. Overall, there were 74 CEs in peripheral IVs (0.25%), of which 12 (4.1%) occurred with USGIVs, and 62 (0.21%) occurred in the 29,217 patients with standard IVs (relative risk 19.4, 95% CI 10.6-35.6; absolute risk difference 3.9%, 95% CI 1.6-6.2%). There were no significant differences between groups in terms of proportion of females (72% of CEs, n=9 and 42 in the USGIV and standard IV groups, respectively), history of ESRD, IVDA, or BMI, or the number of CT angiograms (67% (n=48) of total CEs, 6 in USGIV group and 42 in standard IV group). In the USGIV group, 6 were located in the forearm, 5 in the upper arm, and 1 in the antecubital fossa (AC); there were five 18g and seven 20g IVs in this group. In the standard group, IV location was 28 AC, 24 forearm, 5 upper arm, 4 wrist/hand, and 1 shoulder; there were forty-nine 20g, five 18g, seven 22g, and one 24g IVs. We found that the overall risk of CE with USGIVs placed by RNs to be low (4.1%), but significantly greater compared to IVs placed using standard technique (0.21%). These results are similar to a previously published study, in which USGIVs were placed by physicians. While further study is needed to delineate what, if any, operator characteristics are associated with CEs, our results suggest that USGIVs placed by RNs trained in the procedure perform as well those placed by physicians. Extravasation events are relatively rare, and the small number of CEs in the USGIV group (n=12) did not allow for meaningful comparisons of IV characteristics between the two groups. Larger data sets, likely drawn from multiple institutions (given the relative paucity of extravasations via USGIVs) are needed to ascertain whether IV gauge, location, or catheter length have an affect on contrast extravasation.

Microvascular fluid exchange during CPB with deep hypothermia circulatory arrest or low flow.

Use of deep hypothermic low-flow (DHLF) cardiopulmonary bypass (CPB) has been associated with higher fluid loading than the use of deep hypothermia circulatory arrest (DHCA). We evaluated whether these perfusion strategies influenced fluid extravasation rates and edema generation differently per-operatively. Twelve anesthetized pigs, randomly allocated to DHLF (n = 6) or DHCA (n = 6), underwent 2.5 hours CPB with cooling to 20°C for 30 minutes (min), followed by 30 min arrested circulation (DHCA) or 30 min low-flow circulation (DHLF) before 90 min rewarming to normothermia. Perfusion of tissues, fluid requirements, plasma volumes, colloid osmotic pressures and total tissue water contents were recorded and fluid extravasation rates calculated. During the experiments, cerebral microdialysis was performed in both groups. Microvascular fluid homeostasis was similar in both groups, with no between-group differences, reflected by similar fluid extravasation rates, plasma colloid osmotic pressures and total tissue water contents. Although extravasation rates increased dramatically from 0.10 (0.11) ml/kg/min (mean with standard deviation in parentheses) and 0.16 (0.02) ml/kg/min to 1.28 (0.58) ml/kg/min and 1.06 (0.41) ml/kg/min (DHCA and DHLF, respectively) after the initiation of CPB, fluid filtrations during both cardiac arrest and low flow were modest and close to baseline values. Cerebral microdialysis indicated anaerobic metabolism and ischemic brain injury in the DHCA group. No differences in microvascular fluid exchange could be demonstrated as a direct effect of DHCA compared with DHLF. Thirty minutes of DHCA was associated with anaerobic cerebral metabolism and possible brain injury.

Role of Minimally Invasive Percutaneous Nephrolithotomy Techniques-Micro and Ultra-Mini PCNL (

Management of pediatric stone disease is challenging, with standard percutaneous nephrolithotomy (PCNL) having a good stone-free rate (SFR), but with associated high complication rates. Miniaturization of this technique has led to the rise of minimally invasive PCNL techniques such as micro (<10F) and ultra-mini (<15F) PCNL procedures. Our objective was to perform a systematic review of the literature to evaluate the success and complication rates of minimally invasive PCNL techniques in the pediatric age group (<18 years). A Cochrane style search was performed and the following bibliographic databases were accessed: PubMed, Science direct, Scopus, and Web of Science. This was carried out in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A total of 14 studies (456 patients), including 8 on micro-PCNL (m-PCNL, n = 233) and 6 on ultra-mini PCNL (UMP, n = 223), were included. Mean stone size ranged from 12-16.5 mm (m-PCNL) and 12-41 mm (UMP), and the overall SFR ranged from 80% to 100% (m-PCNL) and 85% to 100% (UMP). The overall complication rates for all studies were 11.2%, which was slightly higher for UMP (13.9%). Postoperative renal colic or fragment obstruction was only seen in m-PCNL, but there was a statistically significant rate of extravasation or renal pelvicaliceal perforation and hematuria for UMP compared with m-PCNL. Miniaturized PCNL techniques can deliver high SFRs with a small risk of Clavien I/II complications. The size of tract seems to influence the nature of complications, with higher hematuria and renal extravasation with increasing tract size.