Routine Use Of Ultrasound Guidance Research Articles

Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia

BackgroundTransfusion guidelines regarding platelet-count thresholds before the placement of a central venous catheter (CVC) offer conflicting recommendations because of a lack of good-quality evidence. The routine use of ultrasound guidance has decreased CVC-related bleeding complications.MethodsIn a multicenter, randomized, controlled, noninferiority trial, we randomly assigned patients with severe thrombocytopenia (platelet count, 10,000 to 50,000 per cubic millimeter) who were being treated on the hematology ward or in the intensive care unit to receive either one unit of prophylactic platelet transfusion or no platelet transfusion before ultrasound-guided CVC placement. The primary outcome was catheter-related bleeding of grade 2 to 4; a key secondary outcome was grade 3 or 4 bleeding. The noninferiority margin was an upper boundary of the 90% confidence interval of 3.5 for the relative risk.ResultsWe included 373 episodes of CVC placement involving 338 patients in the per-protocol primary analysis. Catheter-related bleeding of grade 2 to 4 occurred in 9 of 188 patients (4.8%) in the transfusion group and in 22 of 185 patients (11.9%) in the no-transfusion group (relative risk, 2.45; 90% confidence interval [CI], 1.27 to 4.70). Catheter-related bleeding of grade 3 or 4 occurred in 4 of 188 patients (2.1%) in the transfusion group and in 9 of 185 patients (4.9%) in the no-transfusion group (relative risk, 2.43; 95% CI, 0.75 to 7.93). A total of 15 adverse events were observed; of these events, 13 (all grade 3 catheter-related bleeding [4 in the transfusion group and 9 in the no-transfusion group]) were categorized as serious. The net savings of withholding prophylactic platelet transfusion before CVC placement was $410 per catheter placement.ConclusionsThe withholding of prophylactic platelet transfusion before CVC placement in patients with a platelet count of 10,000 to 50,000 per cubic millimeter did not meet the predefined margin for noninferiority and resulted in more CVC-related bleeding events than prophylactic platelet transfusion. (Funded by ZonMw; PACER Dutch Trial Register number, NL5534.)

Transradial Approach for Pediatric Diagnostic and Neurointerventional Surgery: Single‐Center Case Series and Systematic Review

BackgroundRecent widespread adoption of a transradial approach in adults has encouraged its use and expansion in children; however, the safety and feasibility of the transradial approach in the latter has not been established. We evaluated these characteristics in our pediatric case series and compared our results with those in the literature.MethodsOur prospectively maintained database was retrospectively searched for consecutive patients ≤18 years of age who underwent diagnostic and interventional neuroangiography through the transradial approach. Patient demographics, indications for the procedure, use of ultrasound guidance, arterial size at the access site, intra‐ and postprocedure complications, and outcomes were recorded. For the literature review, systematic searches of PubMed, MEDLINE, and Embase databases were conducted using keywords with Boolean operators (“radial artery” AND “pediatric”) for studies published in English between January 2000 and September 2021. Continuous variables were reported as means or medians and respective standard deviations and interquartile ranges according to data normality. Categorical variables were reported as frequencies.ResultsTwenty‐one patients were included in our series (mean age, 16.6±2.23 years, range 9–17 years; male sex, 11 [52.4%]). The transradial approach was used for diagnostic angiography in 15 cases (71.4%) and intervention in 6 (28.6%). Ultrasound guidance was used and a “radial cocktail” (verapamil‐heparin‐nitroglycerin) was given in all cases. Mean radial artery access‐site diameter was 2.2±0.46 mm. Two cases (9.5%) required conversion to femoral access. Two patients (9.5%) suffered reversible vasospasm. No radial artery occlusion or permanent neurologic deficits were recorded. The systematic review showed results similar to ours for vasospasm rates (6.3% and 9.5%, respectively) and procedural outcomes (92% and 91%, respectively). [Correction added on November 8, 2022, after first online publication: In the preceding sentence, the value 7% was changed to 6.3%, and the value 93% was changed to 92%.]ConclusionOur results and the literature review demonstrate that the transradial approach is a safe and feasible option for pediatric patients. Routine use of ultrasound guidance, selection of appropriately sized catheters, and prophylactic use of vasodilators and antispasmodics can help ensure the success of the procedure and limit common access‐site complications.

Comparison of Frequency of Vascular Complications With Ultrasound-Guided Versus Fluroscopic Roadmap-Guided Femoral Arterial Access in Patients Who Underwent Transcatheter Aortic Valve Implantation

To compare outcomes of ultrasound guidance (USG) versus fluoroscopy roadmap guidance (FG) angiography for femoral artery access in patients who underwent transfemoral (TF) transcatheter aortic valve implantation (TAVI) to determine whether routine USG use was associated with fewer vascular complications. Vascular complications are the most frequent procedural adverse events associated with TAVI. USG may provide a decreased rate of access site complications during vascular access compared with FG. Patients who underwent TF TAVI between July 2012 and July 2017 were reviewed and outcomes were compared. Vascular complications were categorized by Valve Academic Research Consortium-2 criteria and analyzed by a multivariable logistic regression adjusting for potential confounding risk factors including age, gender, body mass index, peripheral vascular disease, Society of Thoracic Surgeons score and sheath to femoral artery ratio. Of the 612 TAVI patients treated, 380 (63.1%) were performed using USG for access. Routine use of USG began in March 2015 and increased over time. Vascular complications occurred in 63 (10.3%) patients and decreased from 20% to 3.9% during the study period. There were fewer vascular complications with USG versus FG (7.9% vs 14.2%, p = 0.014). After adjusting for potential confounding risk factors that included newer valve systems, smaller sheath sizes and lower risk patients, there was still a 49% reduction in vascular complications with USG (odds ratio 0.51, 95% confidence interval 0.29 to 0.88, p = 0.02). In conclusion, USG for TF TAVI was associated with reduced vascular access site complications compared with FG access even after accounting for potential confounding risk factors and should be considered for routine use for TF TAVI.

First case series of the transradial approach for neurointerventional procedures in pediatric patients.

The transradial approach (TRA) has been widely adopted by interventional cardiologists but is only now being accepted by neurointerventionalists. The benefits of the TRA over the traditional transfemoral approach (TFA) include reduced risk of adverse clinical events and faster recovery. The authors assessed the safety and feasibility of the TRA for neurointerventional cases in the pediatric population. Pediatric patients undergoing cerebrovascular interventions since implementation of the TRA at the authors' institution were retrospectively reviewed. Pertinent patient information, procedure indications, vessels catheterized, fluoroscopy time, and complications were reviewed. There were 4 patients in this case series, and their ages ranged from 13 to 15 years. Each patient tolerated the procedure performed using the TRA without any postprocedural issues, and only 1 patient experienced radial artery spasm, which resolved with the administration of intraarterial verapamil. None of the patients required conversion to the TFA. The TRA can be considered a safe alternative to the TFA for neurointerventional procedures in the pediatric population and provides potential advantages. However, as pediatric patients require special consideration due to their smaller-caliber arteries, routine use of ultrasound guidance is advised when attempting the TRA.

Effect of ultrasound-guided central venous catheter insertion on the incidence of catheter-related bloodstream infections and mechanical complications

BackgroundCentral venous catheters (CVCs) are necessary for critically ill patients, including those with hematological malignancies. However, CVC insertion is associated with inevitable risks for various adverse events. Whether ultrasound guidance decreases the risk of catheter-related infection remains unclear.MethodsWe observed 395 consecutive CVC insertions between April 2009 and January 2013 in our hematological oncology unit. Because the routine use of ultrasound guidance upon CVC insertion was adopted based on our hospital guidelines implemented after 2012, the research period was divided into before December 2011 (early term) and after January 2012 (late term).ResultsUnderlying diseases included hematological malignancies and immunological disorders. In total, 235 and 160 cases were included in the early- and late term groups, respectively. The median insertion duration was 26 days (range, 2–126 days) and 18 days (range, 2–104 days) in the early- and late term groups, respectively. The internal jugular, subclavian, and femoral veins were the sites of 22.6, 40.2, and 25.7% of the insertions in the early term group and 32.3, 16.9, and 25.4% of the insertions in the late term group, respectively. The frequency of catheter-related bloodstream infection (CRBSI) was 1.98/1000 catheter days and 2.17/1000 catheter days in the early- and late term groups, respectively. In the subgroup analysis, the detected causative pathogens of CRBSI did not differ between the two term groups; gram-positive cocci, gram-positive bacilli, and gram-negative bacilli were the causative pathogens in 68.9, 11.5, and 14.8% of the cases in the early term group and in 68.2, 11.4, and 18.2% of the cases in the late term group, respectively. In the multivariate analysis to determine the risk of CRBSI, only age was detected as an independent contributing factor; the indwelling catheter duration was detected as a marginal factor. A significant reduction in mechanical complications was associated with the use of ultrasound guidance.ConclusionsUltrasound-guided CVC insertion did not decrease the incidence of CRBSI. The only identified risk factor for CRBSI was age in our cohort. However, we found that the introduction of ultrasound-guided insertion triggered an overall change in safety management with or without the physicians’ intent.

Routine use of ultrasound to avert mechanical complications during placement of tunneled dialysis catheters for hemodialysis

ObjectiveWhile placement of tunneled dialysis catheters for hemodialysis access is considered a routine procedure, it is associated with a small chance of mechanical complications. Because the literature examining these issues is not recent and our impression of the incidence of these postprocedural complications is at variance with the existing literature, we decided to review our experience. MethodsSince 1998, our vascular service has placed 1766 tunneled hemodialysis catheters in 1065 patients for hemodialysis access. All catheters were placed with ultrasound guidance for the puncture, with selective use of a micropuncture set for patients with low-volume status. All patients underwent chest radiography at the end of each procedure. ResultsThe average age of the patients was 61 ± 21 (standard deviation) years. Among the 1065 patients, 44% were female; 93% of catheters were placed in the right internal jugular vein and 7% in the left internal jugular vein. The prevalence of diabetes and hypertension in our population of patients was 52% and 72%, respectively. In this consecutive series, no case of postprocedure hemothorax or pneumothorax was encountered. Two cutdowns had to be performed because of injury to branches of the external carotid artery. Three patients had to have a subsequent revision because of malpositioning of the catheter. ConclusionsUsing modern-day techniques, the incidence of mechanical complications during placement of tunneled catheters can be diminished. Hence, routine use of ultrasound guidance for insertion of tunneled dialysis catheters should become the standard of care.

Ultrasound-guided versus palpation-guided radial artery catheterization in adult population: A systematic review and meta-analysis of randomized controlled trials

BackgroundThe radial artery (RA) is routinely used for both hemodynamic monitoring and for cardiac catheterization. Although cannulation of the RA is usually undertaken through manual palpation, ultrasound (US)-guided access has been advocated as a mean to increase cannulation success rates and to lower RA complications; however, the published data are mixed. We sought to evaluate the impact of US-guided RA access compared with palpation alone on first-pass success to access RA. Methods and ResultsMeta-analysis of 12 randomized controlled trials comparing US-guided with palpation-guided radial access in 2,432 adult participants was done. Hemodynamic monitoring was the most common reason for RA catheterization. Only 2 randomized controlled trials evaluated patients undergoing cardiac catheterization. Ultrasound-guided radial access was associated with increased first-attempt success rate (risk ratio [RR] 1.35, 95% CI 1.16-1.57]) and decreased failure rate (RR 0.52, 95% CI 0.32-0.87). There were no significant differences in the risk of hematoma (RR 0.43, 95% CI 0.27-1.06), the mean time to first successful attempt (mean difference 25.13 seconds, 95% CI −1.06 to 51.34) or to any successful attempt (mean difference −4.74 seconds; 95% CI −22.67 to 13.18) between both groups. ConclusionsUltrasound-guided technique for RA access has higher first-attempt success and lower failure rate compared with palpation alone, with no significant differences in access site hematoma or time to a successful attempt. These findings support the routine use of US guidance for RA access.

Routine Use of Ultrasound Guidance in Femoral Arterial Access for Peripheral Vascular Intervention Decreases Groin Hematoma Rates in High-Volume Surgeons

There is a documented learning curve when adopting ultrasound guidance (UG) to aid vascular access. In the Vascular Study Group of New England (VSGNE), routine UG during percutaneous femoral artery access was shown to protect against the complication of groin hematoma. We sought to confirm this finding in the Vascular Quality Initiative (VQI), a data set with a larger sample size and broader geographic distribution, and to evaluate the effects of ultrasound usage and interventionalist volume on hematoma rates following peripheral vascular interventions (PVIs). The VQI PVI database (2010-2014) was queried to identify the complication of groin hematoma after 43,947 PVIs performed via femoral artery access. Both procedure- and interventionalist-level analyses were performed. Multivariable logistic regression was used to assess factors associated with hematoma. Multivariable Poisson regression analyses were used to compare hematoma rates between routine (≥80% of PVIs) and selective (<80% of PVIs) users of UG in the adjusted overall sample and in subgroups based on interventionalist volume (low: <10 PVIs/year; medium: 10-50 PVIs/year; high: >50 PVIs/year). The overall groin hematoma rate was 3.2%, and lower hematoma rates correlated with increasing annual interventionalist volume (low vs. medium vs. high volume: 3.7% vs. 3.4% vs. 2.9%; P=0.011). UG was associated with increased risk of hematoma (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.13-1.47, P<0.001), but this risk was isolated to patients treated by selective (OR 1.33, 95% CI 1.17-1.53, P<0.001) rather than routine users of UG (OR 0.85, 95% CI 0.55-1.33, P=0.484). In the overall interventionalist-level analysis, routine UG was not found to be protective against hematoma (rate ratio [RR] 0.97, 95% CI 0.85-1.11, P=0.677), in contrast to what was previously reported from the VSGNE. However, subgroup analysis revealed that routine UG was further protective against hematoma among high-volume interventionalists (RR 0.73, 95% CI 0.54-0.97, P=0.030). UG in percutaneous femoral artery access may decrease the complication rate of groin hematoma, especially as an interventionalist's volume increases and as selective use transforms into routine adoption. With repetition and practice, interventionalists likely overcome the learning curve associated with adoption of an unfamiliar technology and potentially improve patient outcomes.

Easier and Safer Regional Anesthesia and Peripheral Nerve Block under Ultrasound Guidance.

Regional anesthesia for the peripheral nerve or plexus has been widely used in the management of acute or chronic pain. To deliver a smaller volume to the targeted nerve without injury to it or its surrounding structures can be critical in the practice of regional anesthesia [1]. Therefore, the identification of the target nerve is important to provide better efficacy and safety in regional anesthesia. To increase the success rate of target nerve blocks, an electrical nerve stimulation device is popularly used. However, in spite of the use of a nerve stimulator, it is sometimes difficult to identify the exact position of the tip of the needle [2]. Since 1978, ultrasound has been widely used in several kinds of regional anesthetic practices. Recently, the improvements in ultrasound technology allow you to place the tip of the needle near the targeted nerve and monitor the spread of the local anesthetics precisely. In addition, ultrasound guidance enables the physician to replace the needle in the case of mal-distribution of the local anesthetic in real time. Therefore, ultrasound-guided technique has been considered the gold standard for performing regional anesthesia or peripheral nerve blocks [3]. The interscalene brachial plexus (IBP) block is very useful for upper extremity surgery. But IBP at the C6 level often fails to affect the ulnar nerve in up to 50% of blocks [4]. Kim et al. [2] injected 55 ml of local anesthetic via low approach IBP below the C6 level using a nerve stimulator for upper extremity surgery. A low approach IBP provided more caudad spread of local anesthesia in the brachial plexus, resulting in a better efficacy in blocking the ulnar nerve than the conventional IBP approach at the C 6 level (46% vs 81%; P < 0.0001). However, it may be associated with several concerns. The vertebral artery enters deep into the transverse process at the level of C6 or C7. Therefore, a nerve stimulant guided low approach IBP below the C6 level increases the risk of vertebral artery puncture, which may result in catastrophic outcomes. The nerves from C5 and C6 innervate the upper arm or forearm. When muscular twitching in the forearm is observed, it is difficult to identify whether the motor response originates from the C5 or C6 nerve. And thus, it is difficult to identify the exact position of the tip of the needle from the nerve stimulation. In this issue, Park et al. [5] reported the effect of ultrasound guided low approach IBP for upper limb surgery. They used 40 ml of local anesthetics for IBP, which provided adequate anesthesia without any significant complications in all 20 patients. Ultrasound provides direct visualization of the best site for the injection and helps avoid incidental puncture of blood vessels and damage to nerves. In addition, the volume of local anesthetic needed can be reduced by monitoring the spread of local anesthetics. Thus, continuously observing the distribution of local anesthetic and replacing the needle when mal-distribution of the injectate occurs improves the efficacy and safety of regional anesthesia or peripheral nerve block under ultrasound guidance. Substantially, the use of ultrasound can decrease the performance time of regional anesthesia, which may promote the routine use of ultrasound guidance in regional anesthesia. Therefore, it is justified to enable physicians to acquire the knowledge and techniques to use ultrasound guidance in regional anesthesia and in performing peripheral nerve blocks.

Abstract P2-05-02: Preliminary translational results from PROMIX, a phase II trial of preoperative chemotherapy with the addition of bevacizumab in large operable and locally advanced HER2-negative breast cancer

Abstract Background: Preoperative chemotherapy in breast cancer (bc) provides unique possibilities to evaluate effects of therapy by studying response and changes in the tumor during the course of treatment. A pathologic complete response (pCR) correlates positively with long term prognosis in high-proliferating bc. In triple negative bc (TNBC) the prognosis was still relatively serious in cases with pCR in one large meta-analysis (Cortazar Lancet 2014). Methods: 150 cases were included in this multicenter study, and treated with six cycles of epirubicin and docetaxel, adding bevacizumab from cycle 3, before surgery. Core needle biopsies were collected at free hand or with ultrasound (US) guidance and snap frozen at base-line and after cycle 2, tissue was also collected at surgery. Subtyping was performed using immunohistochemistry (IHC) of ER, Ki67 and HER2 according to modified St Gallen criteria; and using bead array gene expression profiling (GEX) according to PAM50. Results: Biopsies were successfully retrieved from 145/150 pts at baseline, 138 after cycle 2 and 139 at surgery. The mRNA yield was adequate for GEX from 123/145 (85%) at baseline, 82/138 (59%) at cycle 2 and 71/139 (51%) at surgery, the decrease being a result of tumor shrinkage during treatment. Initial PAM50 subtypes were as follows: luminal A (LA) 20%, luminal B (LB) 45%, HER2 5 %, basal like (BL) 22% and normal like (NL) 8%. PAM50 at baseline differed compared to IHC subtypes. Among IHC defined LA-like cases 15/33 (45%) were classified as LB by PAM50. Similarly, among IHC LB-like 22/57 (39%) were classified as non-LB (6 basal, 8 LA, 3 HER2 and 5 NL), while among IHC TNBC 7/28 (25%) were classified as non-BL subtypes (1 LA, 3 HER2 and 3 NL). Of the pts with a baseline GEX analysis, 17 (14%) achieved a pCR. The observed pCR rates among PAM50 subtypes were: LA 8%, LB 5%, HER2 17%, BL 53% and NL 20%. For non-pCR cases, 39/52 (75%) of the tumors changed PAM50 subtype between baseline and surgery. The majority changed to the NL subtype. 33% of the LB tumors changed to the LA subtype. Currently, after 2.2 years of follow-up, 16 pts are deceased due to bc. Among BL cases, 6/9 pts with a pCR at surgery remain alive; while 3/9 have died from bc. Exploratory analyses using functional gene modules (Desmedt Clin Cancer Res 2008) suggest that patients with BL tumors who have died have higher scores for PLAU/invasion and lower scores for STAT1/immune response compared with those who are still alive. Tumor size at baseline did not obviously correlate with outcome. Conclusion: We show that biological material can be retrieved from a substantial fraction of cases treated within a multicenter study of preoperative chemotherapy. The success rate may be ameliorated by routine use of US guidance. The distribution of subtypes differs between modified IHC St Gallen criteria and PAM50, especially within the luminal subtypes. The pCR rate is highest among cases with a BL tumor at baseline. Shift of the gene signature between different subtypes during the course of treatment is frequent. In this set of relatively large tumors, the prognosis among BL bc appears to be adverse in spite of a pCR. Citation Format: Niklas Loman, Ida Johansson, Judith Bjöhle, Jan Frisell, Tobias Lekberg, Lisa Rydén, Anna von Wachenfeldt, Jonas Bergh, Thomas Hatschek, Ingrid Hedenfalk. Preliminary translational results from PROMIX, a phase II trial of preoperative chemotherapy with the addition of bevacizumab in large operable and locally advanced HER2-negative breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-05-02.

Routine use of ultrasound guidance in femoral arterial access for peripheral vascular intervention decreases groin hematoma rates

Use of fluoroscopy and bone landmarks to guide percutaneous common femoral artery (CFA) access has decreased access site complications compared with palpation alone. However, only limited case series have examined the benefits of ultrasound to guide CFA access during peripheral vascular intervention (PVI). We evaluated the effect of routine vs selective use of ultrasound guidance (UG) on groin hematoma rates after PVI. The Vascular Study Group of New England database (2010-2014) was queried to identify the complication of postprocedural groin hematoma after 7359 PVIs performed through CFA access. Hematoma (including pseudoaneurysms) was defined as minor (requiring compression or observation), moderate (requiring transfusion or thrombin injection), and major (requiring operation). Both procedure-level and interventionalist-level analyses were performed. Multivariable Poisson regression models were used to compare hematoma rates of interventionalists based on routine (≥80% of PVIs) and selective (<80%) utilization of UG in the adjusted overall sample and in multiple subgroups. The overall postprocedural groin hematoma rate after PVI was 4.5%, and the rate of combined moderate and major hematoma was 0.8%. Among 114 interventionalists with ≥10 PVI procedures, routine and selective UG was used by 31 (27%) and 83 (73%) interventionalists, respectively. Routine UG was protective against hematoma (rate ratio [RR], 0.62; 95% confidence interval [CI], 0.46-0.84; P < .01). Subgroup analysis revealed that routine UG was also protective against hematoma under the following circumstances: age >80 years (RR, 0.47; 95% CI, 0.27-0.85; P = .01), body mass index ≥30 (RR, 0.51; 95% CI, 0.29-0.90; P = .02), and sheath size >6F (RR, 0.43; 95% CI, 0.23-0.79; P < .01). Routine UG may potentially protect against the complication of hematoma for both modifiable and nonmodifiable patient and procedural characteristics. Encouraging routine UG is a feasible quality improvement opportunity to decrease patient morbidity after PVI.

Routine Use of Ultrasound Guidance in Femoral Arterial Access for Peripheral Vascular Intervention Decreases Groin Hematoma Rates

Use of fluoroscopy and bony landmarks to guide percutaneous common femoral artery (CFA) access has decreased access site complications compared with palpation alone. However, only limited case series have examined the benefits of ultrasound imaging to guide CFA access during peripheral vascular intervention (PVI). We evaluated the effect of routine vs selective use of UG on groin hematoma rates after PVI. The Vascular Study Group of New England database (2010-2014) was queried to identify the complication of postprocedural groin hematoma after 7359 PVIs performed by CFA access. Hematoma (including pseudoaneurysms) was defined as minor (requiring compression or observation), moderate (requiring transfusion or thrombin injection), and major (requiring operation). Multivariable Poisson regression models were used to compare hematoma rates of surgeons based on routine (≥80% PVI) and selective (<80%) use of UG in the adjusted overall sample and in multiple subgroups. The overall groin hematoma rate after PVI was 4.5%, and the rate of combined moderate and major hematoma was 0.8%. Among 114 surgeons with ≥10 PVI procedures, 31 surgeons (27%) used UG routinely and 83 (73%) used UG selectively. Routine UG was protective against hematoma (rate ratio [RR], 0.74; 95% confidence interval [CI], 0.57-0.95; P = .02). Subgroup analysis revealed that routine UG was also protective against hematoma under the following circumstances: age >80 years (RR, 0.47; 95% CI, 0.26-0.85; P = .01), body mass index ≥30 kg/m2 (RR, 0.51; 95% CI, 0.29-0.90; P = .02), timing of procedure in the first half of the academic year (RR, 0.56; 95% CI, 0.38-0.82; P < .01), and sheath size >6F (RR, 0.43; 95% CI, 0.23-0.79; P < .01). Routine UG may potentially protect against the complication of hematoma for modifiable and nonmodifiable patient/procedural characteristics. Encouraging routine UG is a feasible quality improvement opportunity to decrease patient morbidity after PVI.

A lost guidewire.

Sir, Central venous cannulation is one of the most common procedures performed in any intensive care unit. The incidence of mechanical complications i.e., pneumothorax, arterial injury etc., are reduced with an experienced operator and routine use of ultrasound guidance for insertion of the catheter.[1] Various complications related to guidewire can happen during the insertion process e.g., kinking, loss, breakage, and knotting of guidewire. Some guidewire problems e.g., breakage or loss can lead to adverse consequences.[2] Here, we describe a case where a guide wire was lost during insertion of a femoral central line and was not recognized until several hours later. A 46-year-old woman was diagnosed with severe community acquired pneumonia, respiratory failure, septic shock, and acute renal failure. In the emergency room, a right subclavian vein central venous line was placed and after initial volume resuscitation, vasopressors were started. She was intubated, placed on mechanical ventilation and transferred to the medical intensive care unit. Over the next 24-h, a left peripherally inserted central venous catheter and a right femoral central venous line were placed to obtain adequate access for monitoring and treatment. A routine chest X-ray performed 18 h after the placement of the right femoral central venous line, detected a guidewire lodged partly in the heart [Figure 1 and Figure 2a, arrowhead]. With bedside ultrasonography, the guidewire could be traced in the inferior vena cava (IVC) up to the level of the renal veins [Figure 2b, sagittal plane view of IVC with guidewire (arrow); Figure 2c shows transverse section of IVC at the confluence of hepatic veins, with guidewire (arrow); Figure 2d shows transverse section of IVC at the level of renal veins showing guidewire (arrow)]. She was taken to the interventional radiology suite where under fluoroscopic guidance, the right femoral catheter was carefully removed. The proximal straight end of the guidewire was found inside the tip of the central venous catheter. It was grasped and removed uneventfully with a steady gentle pull. Figure 1 Chest X-ray showing misplaced guide wire Figure 2 (a) Chest X-ray showing a guide wire lodged partly in the heart (arrowhead); (b) longitudinal view of inferior vena cava (IVC) with guide wire (arrow); (c) transverse section of IVC at the confluence of hepatic veins, with guidewire (arrow); (d) transverse ... Loss of the guidewire inside the vessel is a serious complication of central venous line placement. In this case report, the guidewire was lost during insertion and not recognized by an operator, judged competent in a residency training setting to perform the procedure independently, until many hours later. Similar complications have been reported in literature.[3,4] Serious consequences include perforation of vascular and cardiac structures. Difficult management issues arise as it often involves transport of clinically unstable patients outside intensive care unit environment for removal of the guidewire. We believe that the complication happened due to failure to adhere to good practice, e.g., withdrawing the guidewire until the proximal end comes out of the catheter port and holding the guidewire while advancing the catheter beyond the skin entry site. A meticulous attention to standard precautions can prevent this untoward and avoidable complication.

Elimination of pneumothorax and hemothorax during placement of implantable venous access ports using ultrasound and fluoroscopic guidance

Implantable venous access ports are essential for patients requiring chronic venous access. Ultrasound guided catheter placement has been recognized as a valuable adjunct for reducing complications during placement of access ports in the radiology and critical care medicine literature. We reviewed the medical records of patients undergoing insertion of implantable venous access ports from June 2006 through June 2009. All procedures were performed using ultrasound guidance with the internal jugular vein as the access site. There were 500 implantable venous access ports placed and included for review. There were no post-procedure pneumothoraces or hemothoraces. Carotid puncture was documented in 4 (0.8%)cases. Routine use of ultrasound guidance during placement of implantable venous access ports has eliminated the complications of pneumothorax and hemothorax during placement of internal jugular venous access ports on our vascular surgery service. Elimination of these complications and decreased use of chest x-rays should also provide increased cost savings for this procedure.

Who Should Be Performing Liver Biopsies?

Who Should Be Performing Liver Biopsies?

An Argument for Routine Ultrasound Screening of the Thoracic Aorta in the Cardiac Surgery Population

Stroke and neurological injury are among the most devastating and disabling complications associated with cardiac surgery. Transesophageal echocardiography and epiaortic ultrasound allow for sensitive, point-of-care diagnosis of thoracic aortic disease, which is especially common in patients with heart disease. Unlike other operative procedures, the manipulation of the ascending aorta is routine in cardiac surgery and often unavoidable. Dislodgement and embolization from the ascending and aortic arch atheromas have been clearly associated with manipulation during cardiac surgery. Epiaortic ultrasound and transesophageal echocardiography screening are more accurate and more accessible to the operative team than any other available modality to diagnose atherosclerosis of the aorta. The goal of this review is to review the rationale and scientific evidence that suggests that the routine use of ultrasound guidance in cardiac surgery may improve postoperative outcomes in this patient population.

Effect of the implementation of NICE guidelines for ultrasound guidance on the complication rates associated with central venous catheter placement in patients presenting for routine surgery in a tertiary referral centre

The National Institute for Clinical Excellence (NICE) guidelines of 2002 recommended the use of ultrasound (US) for central venous catheterization in order to minimize complications associated with central line placement. An ongoing audit of line placement by anaesthetists in the theatre complex of a tertiary referral centre looked at the associated complication rates. The objective of the study was to compare complication rates pre- and post-implementation of NICE guidelines. This prospective, single centre audit looked at all patients in whom a central venous catheter was placed for surgery. Complication rates were assessed for procedures that were performed pre- and post-implementation of NICE guidelines. In total, 438 patients were identified for the study, and the procedures were performed either by trainee or by consultant anaesthetists. The pre- and post-implementation complication rates were 10.5% (16/152) and 4.6% (13/284), respectively, representing an absolute risk reduction of 5.9% (95% CI 0.5-11.3%). Comparison of those procedures in which US was used when compared with the landmark technique after implementation found a reduction of 6.9% in complications (95% CI 1.4-12.4%). The reduction in complication rates was larger for specialist registrars than for consultants (11.2% vs 1.6%). The implementation of NICE guidelines has been associated with a significant reduction in complication rates in our tertiary referral centre. In the light of the cross-speciality evidence of US superiority and our results, it is imperative that routine use of US guidance becomes more widespread.

Outpatient liver biopsy using ultrasound guidance and the Biopty gun is safe and cost effective.

The need for liver biopsy is increasing with the increasing availability of treatments for liver disease, in particular interferon. For this reason the procedure must be efficient and economical, as well as safe. Firstly to assess the safety of outpatient liver biopsy when performed with ultrasound guidance and the 'Biopty' gun. Secondly, to compare the cost of an outpatient and inpatient procedure. Two hundred and fifty consecutive liver biopsies performed over a two year period at St Vincent's Hospital, Melbourne were reviewed retrospectively. Indications, histological findings and complications were recorded. Seventy per cent of the biopsies were performed as an outpatient procedure. There were no major complications. Four patients experienced prolonged pain post biopsy. The average cost for an outpatient biopsy was $351, the cost of an inpatient (overnight stay) was $690. Outpatient liver biopsy is safe and cost effective, with minor complications in 1.6%. The routine use of ultrasound guidance and the Biopty gun is likely to contribute to these favourable results.