Catheter Set Research Articles

Reconstruction of a Fletcher type applicator with a CT/MR compatible catheter using MR imaging for cervical cancer brachytherapy

The purpose of this study was to investigate the clinical feasibility of Fletcher-Williamson (FW) applicator reconstruction and to report on the use of such reconstructions in treatment planning for magnetic resonance imaging (MRI)-based brachytherapy of locally advanced cervical cancer. We constructed a phantom containing a fixed standard CT/MRI applicator set, and six fixed spheres filled with Ultravist, representing reference dose points (P1 ∼ P6). CT and two MRI image sets of the phantom, including a standard CT/MR applicator with inserted National Cancer Center (NCC) CT/MR catheter sets developed in-house, were scanned for brachytherapy treatment planning. The results were compared with traditional two-dimensional film-based treatment planning. Catheter reconstruction for each plan was performed with a 2.5 mm source step and repeated five times using a routine protocol for four different imaging sets to verify reproducibility in radiation treatment planning. From all calculated dose distributions, doses at the P1 P6 reference points were acquired for all reconstruction methods, and treatment planning was repeated. Based on MR imaging, 3D applicator reconstruction was performed for FW type applicators, and the Plan and the PlanMR−N demonstrated excellent agreement, with a maximum difference of 1.5% in the average dose distribution at all six reference points. However, Plan and PlanMR−G showed significant variations (6.5%) at some points and for relative standard deviations (SD). Our preliminary phantom study indicates that, for cervical cancer brachytherapy, reconstruction of a Fletcher-type applicator with a CT/MR-compatible catheter using MRI is feasible and shows excellent reproducibility and accuracy for clinical implementation.

Intubation through the LMA-Supreme™: A Pilot Study of Two Techniques in a Manikin

The LMA-Supreme is a single-use disposable laryngeal mask that combines features of several laryngeal mask airways in one device. The primary aim of our study was to compare ease of use and operator preference for fibreoptic-aided intubation through the LMA-Supreme using an Aintree Intubating Catheter or Arndt Airway Exchange Catheter Set. Twenty participants experienced in fibreoptic-aided intubation performed a total of 40 intubations on an AirSim airway manikin through a #4 LMA-Supreme. Intubation using the Arndt Airway Exchange Catheter Set was easier than with the Aintree Intubating Catheter. Half of the participants preferred Aintree Intubating Catheter-assisted intubation, citing fewer steps and faster performance as the reasons. All 20 (100%) Arndt Airway Exchange Catheter Set-assisted intubations and 18/20 (90%) of Aintree Intubating Catheter-assisted intubations were successful. Aintree Intubating Catheter and Arndt Airway Exchange Catheter Set-assisted intubations can be performed quickly, successfully and with minimal difficulty through the LMA-Supreme by experienced operators. While the Arndt Airway Exchange Catheter may be easier the Aintree Intubating Catheter is faster.

Design flaw of Melker kit may compromise patient safety

Some investigators have demonstrated poor performance for first time users of the Melker Universal Cricothyrotomy Catheter Set® (Cook, Bloomington, IN, USA) [1, 2]. In contrast, two previous studies have reported high success rates with the same equipment [3, 4]. The conflicting results may be secondary to varied method, however we are concerned it may reflect poor human factor engineering [5]. In a previous study, we observed 22 anaesthetic trainees performing a cricothyrotomy on cadavers [2]. Participants had no prior hands-on instruction of the Melker kit. We observed frequent incorrect handling of the dilator and airway cannula following guide wire placement. We measured the time from a subject’s first attempt to insert the dilator, with or without it being placed appropriately within the airway cannula, until the successful establishment of a definitive airway or abandonment of the cricothyrotomy. Thirty-six per cent were unsuccessful in placing the Melker kit in the trachea because of failure to load the catheter onto the dilator. Performance in successfully establishing an airway is shown in Fig. 2. ‘Correct’ refers to use of Melker kit as per manufacturer’s instructions (n = 4); ‘no wire’ refers to a failure to use the guide wire when inserting the cannula and dilator (n = 2); ‘no dilator’ refers to insertion of the catheter without it being loaded onto the dilator (n = 2); ‘dilated separately’ refers to dilation before insertion of the cannula then loaded onto the dilator (n = 6). Our results suggest that many first time users did not intuitively recognise that the cannula needs to be loaded onto the dilator prior to insertion. This confusion led to increased time and failure to achieve a definitive airway. These findings are consistent with the study by Dimitriadis et al. [1] where the human factor errors using the kit were similar. Cook Medical® produces a version of the Melker kit that has both the 4 and 6 mm internal diameter cannulae with the dilator preloaded inside the catheter and we suggest that the individually packed Melker kit should be similarly preloaded or discontinued to help prevent potential failure.

Continuous paravertebral block in a patient with multiple rib fractures: a radiological conundrum?

Free AccessCorrespondenceContinuous paravertebral block in a patient with multiple rib fractures: a radiological conundrum?S Mannion and M MurphyS MannionDepartments of 1Anaesthesiology and 2Radiology, South InfirmaryVictoria University Hospital, Cork, IrelandSearch for more papers by this author and M MurphyDepartments of 1Anaesthesiology and 2Radiology, South InfirmaryVictoria University Hospital, Cork, IrelandSearch for more papers by this authorPublished Online:28 Jan 2014https://doi.org/10.1259/bjr/83773691SectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail AboutThoracic paravertebral block (PVB) is a peripheral nerve block technique that blocks the thoracic somatic spinal nerves in the paravertebral space. The boundaries of the thoracic paravertebral space are traditionally defined as the parietal pleura anteriorly, the costotransverse ligament posterolaterally and limited by the vertebral bodies medially [1]. As PVBs are usually performed in the operating theatre or pain clinic setting, they may be unfamiliar to other medical specialists. A loss-of-resistance technique (LORT) is commonly employed to locate the paravertebral space [1]. The passage of the block needle through the costotransverse ligament and hence into the paravertebral space is detected as a loss of resistance to air or saline. The use of air for this technique will result in air entering the paravertebral space. Continuous PVB has been described in the pain management of patients with multiple rib fractures [2]. We describe a case of a continuous PVB in a patient with multiple rib fractures presenting as a radiological diagnostic conundrum.A 65-year-old man presented with left-sided rib fractures of the 6th to 8th ribs, following a fall. He had a background history of chronic obstructive pulmonary disease. The pain team were asked to review him because he had developed a left basal consolidation and was unable to cough or expectorate sputum because of thoracic pain. A left-sided continuous PVB was performed using a LORT with air and an 18 G Tuohy needle and epidural catheter set. The block was performed at the T7 level, 2.5 cm from the midline. Needle entry into the paravertebral space was confirmed by loss of resistance with 3–5 ml of air. 15 ml of 0.25% bupivacaine with adrenaline (1:200 000) was administered and the catheter inserted. After 15 min, the patient had good pain relief and was able to cough vigorously. 30 min after block performance, the patient underwent a CT of the thorax as part of his respiratory investigations.The radiologist reviewing the CT scan was unaware that a PVB had been performed and reported evidence of air (2–3 ml) outside the left parietal pleura (Figure 1). This was suggestive of a small pneumomediastinum secondary to multiple rib fractures. There followed a period of confusion as to whether this was a resolving or new finding. However, subsequent communication with the pain team confirmed the cause of the diagnosis.This case highlights the need for good communication between healthcare professionals, especially when unfamiliar anaesthetic or analgesic techniques are used. These CT images also confirm previous MRI [3] and radiological [4] findings in that the medial boundary of the paravertebral space can extend anteriorly to the vertebral bodies via the areolar connective tissue between the vertebral bodies and the endothoracic fascia [5].Figure 1. The white arrow indicates air in the paravertebral space with spread medially, anterior to the verterbral body. Download Figure References 1 Vila H Jr, Liu J, Kavasmaneck D. Paravertebral block: new benefits from an old procedure. Curr Opin Anaesthesiol 2007;20:316–8. Crossref Medline ISI, Google Scholar2 Karmakar MK, Critchley LA, Ho AM, Gin T, Lee TW, Yim AP. Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs. Chest 2003;123:424–31. Crossref Medline ISI, Google Scholar3 Barrett J, Harmon D, Loughnane F, Finucane B, Shorten G. Paravertebral block. In: Barrett J, Harmon D, Loughnane F, Finucane B, Shorten G, editors. Peripheral nerve blocks and peri-operative pain relief. 1st edn. Philadelphia, PA: WB Saunders, 2004. 135–38. Google Scholar4 Karmakar MK, Kwok WH, Kew J. Thoracic paravertebral block: radiological evidence of contralateral spread anterior to the vertebral bodies. Br J Anaesth 2000;84:263–5. Crossref Medline ISI, Google Scholar5 Karmakar MK, Gin T, Ho AM. Ipsilateral thoraco-lumbar anaesthesia and paravertebral spread after low thoracic paravertebral injection. Br J Anaesth 2001;87:312–6. Crossref Medline ISI, Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 82, Issue 981September 2009Pages: 705-e193 © The British Institute of Radiology History RevisedJune 11,2009ReceivedJune 07,2009Published onlineJanuary 28,2014 Metrics Download PDF

Treatment and prevention of Candida albicans biofilms with caspofungin in a novel central venous catheter murine model of candidiasis

We sought to develop a novel model of central venous catheter (CVC)-associated candidiasis in mice and to use this model to examine the efficacy of caspofungin to treat and prevent Candida albicans biofilms in vivo. We used catheterized mice, commercially available from the National Cancer Institute, to form C. albicans biofilms inside CVCs. Once the model was developed, we examined the efficacy of caspofungin for the treatment of preformed biofilms and for the prevention of C. albicans biofilm formation. We developed a relatively simple murine model of CVC-associated candidiasis that minimized the number of manipulations necessary for in vivo biofilm formation. C. albicans biofilms formed in vivo display structural features similar to those observed for models of in vitro- and other in vivo-formed biofilms. Following model development, 0.25 microg/mL of caspofungin was instilled in the catheter to treat preformed biofilms. The results indicated that caspofungin treatment significantly reduced biofilm fungal load in the catheters and dissemination to kidneys compared with untreated controls. In a second set of experiments catheters were pre-treated by filling with 60 microg/mL of caspofungin before challenge with C. albicans via the CVC. Again, the results indicated a significant reduction in biofilm fungal load and dissemination to kidneys compared with untreated controls. We have developed a novel model of CVC-associated candidiasis in mice. Using this model we demonstrate the efficacy of caspofungin for the treatment and prevention of C. albicans biofilms in vivo.

Peritoneal catheter for continuous drainage of ascites in advanced cancer patients

Advanced cancer patients with refractory ascites do not often respond to dietary sodium restriction and diuretics. While paracentesis is effective, the condition invariably recurs, necessitating repeated procedures. A continuous peritoneal drainage by an indwelling catheter has been reported to be hugely beneficial symptomatically, avoiding the hazards and disadvantages of multiple repeated procedures and direct and indirect costs. Forty patients with advanced cancer patients admitted to an acute pain relief and palliative care unit, who presented symptomatic ascites, were recruited for continuous drainage of peritoneal fluid. A central venous catheter set for Seldinger technique was used. Technical failure was defined as an unsuccessful drainage of fluid through the catheter. Immediate and late complications, including hypotension, haemorrhage, tube blockage, dislodgment and sepsis were recorded. Record of daily drainage during admission were noted. At time of discharge, patients were asked to rate their global symptom burden as improved, unchanged or worsened. The follow-up was performed with frequent phone contacts or day-hospital admission in case of problems. The mean patients' age was 68 years, and 21 were men. Patients were receiving unsuccessfully a mean dose of furosemide of 32 mg/day. The technique was not painful and was easily accepted by patients. Insertion was technically successful in almost all patients. Mean admission time was 5.5 days (range 2-14), and the mean drained volume during admission was 8,499 ml (range 800-20,700), 2,850 ml (300-4,200) being drained on the first 24 h. No immediate complications were recorded. Six patients died during admission. The mean survival was 38.9 days (range 1-120). Of the 34 patients who were discharged home, 22 patients stated that symptom burden had improved, while in 10 patients symptom burden did not change or worsened, probably due to the advanced status of diseases and multiple contributing factors. Five, two, and one patients required skin sutures at 1, 2 and 3 months, respectively. About one third of patients had mechanical problems, some of them requiring a catheter replacement. No infection was recorded. In conclusion, a permanent peritoneal catheter was a valuable method to remove abdominal fluids and reduce symptom burden attributable to ascites and was also easy to use at home. Complication rate was acceptable and balanced by the benefits of the technique which avoided frequent paracentesis and associated complications.

Ectopic atrial tachycardias with early activation at His site: radiofrequency ablation through a retrograde approach

The purpose of this study was to evaluate a retrograde approach for radiofrequency (RF) ablation of ectopic atrial tachycardias (EATs) with an early atrial activation at the His site. This study included 12 patients with EAT. During tachycardia, earliest atrial activation was recorded at the His site at a standard catheter setting. Activation mapping was performed in the right atrium and along the mitral annulus and at the aortic root after retrograde insertion of the ablation catheter over the ascending aorta. In five patients, earliest atrial activation was recorded at the mitral annulus (in two patients at the superior-lateral annulus and in three patients at the inferior-medial annulus). In four of these patients, EAT could be successfully treated by RF ablation through the retrograde approach, whereas in one patient, a transseptal puncture was performed in order to achieve a stable catheter position. In seven patients, RF ablation at the non-coronary aortic sinus eliminated the tachycardia. During a follow-up period of 14 +/- 8 months, there was no tachycardia recurrence. In patients with EATs and early atrial activation at the His site, tachycardia may arise in the non-coronary aortic sinus or from the mitral annulus. Radiofrequency energy ablation can be performed through a retrograde approach in the majority of these patients and is safe and effective in eliminating this type of tachycardia.

Technical Notes and Tips: Use of a Peel-Away Trocar Sheath to Assist Suprapubic Catheter Replacement

Suprapubic catheter replacement, particularly after recent insertion, can be difficult and may be complicated by bladder retraction and loss of the track. We present a simple technique to aid catheter replacement using the peel-away trocar sheath found in most suprapubic catheter sets (Fig. 1). The patient is given prophylactic antibiotics and prepared using sterile technique. The sheath is placed around the existing catheter after removal of the peel-away section (Fig. 2). The sheath is then advanced 2–3 cm into the bladder using lignocaine gel for lubrication. The existing catheter can then be exchanged safely, followed by removal of the sheath. Figure 1 Typical suprapubic catheter set. Figure 2 Peel-away trocar sheath.

Efficacy of Continuous Femoral Nerve Block With Stimulating Catheters Versus Nonstimulating Catheters for Anterior Cruciate Ligament Reconstruction

This prospective randomized controlled trial investigated the clinical efficacy of stimulating catheters for continuous femoral nerve block in patients who underwent anterior cruciate ligament reconstruction. Seventy patients were randomized to either a stimulating catheter (SC, n = 35) or a nonstimulating catheter (NSC, n = 35) for femoral nerve block using 25 mL ropivacaine 7.5 mg/mL and clonidine 50 microg injected through the catheter. A single-injection sciatic block was also given to ensure surgical anesthesia. The time to loss of sensation to cold and pinprick of the femoral nerve was registered as the onset time. Data were registered intra- and postoperatively regarding pain scores, adverse effects, and need for supplemental anesthesia and analgesia other than a continuous postoperative infusion of ropivacaine 2 mg/mL through the continuous femoral nerve catheter set at 7 mL/h. Onset time was faster in the SC group (SC: 6.4 +/- 2.5, NSC: 8.3 +/- 2.9 min, P = .006). Visual analog scale pain scores were similar in both groups. The number of patient-controlled regional analgesia boluses (SC: 14.6 +/- 12.6, NSC: 23.2 +/- 13.6 mg ropivacaine 2 mg/mL, P = .008) as well as intravenous rescue ketorolac (SC: 34.3 +/- 35.7, NSC: 54 +/- 39.7 mg, P = .033) administered were higher in the NSC group. Although the use of a stimulating catheter was associated with faster onset time for the femoral nerve block and lower additional analgesics postoperatively, the clinical superiority (analgesia; lateral femoral cutaneous, and obturator nerve block) of stimulating catheters was not evident in this clinical setting.

Ponction de la membrane intercricothyroïdienne pour l'oxygénation en urgence : évaluation d'une formation

IntroductionTranstracheal oxygenation is a lifesaving technique in a cannot-ventilate, cannot-intubate situation, in setting percutaneous transtracheal catheter. ObjectiveTo assess training for cricoid membrane puncture performed with a Ravussin needle. MethodTen residents in anaesthesiology nearing completion of their training participated in the study. Following a didactic session and a video demonstration, participants performed percutaneous transtracheal punctures on fresh cadavers. Success rate and time to perform the puncture were measured. Results are expressed as mean±SD. ResultsBy the third attempt, all procedures were successful. Mean performance time at the first attempt was 31.2±21.8 s, progressively decreasing with the following attempts to reach a plateau by the third attempt (20.6±19.3s). Performance time varies with the cadaver's morphology and the ability to recognize anatomic landmarks. However, whatever the difficulty, performance time is 40 s or less by the third attempt. ConclusionPercutaneous transtracheal catheter setting is a life saving technique with which every anaesthesiologist should be familiar. Viewing a pedagogic videotape and training on cadavers provides a rapid and effective training method for cricoid membrane puncture. Four attempts seem necessary to obtain an optimal success rate.

Ultrasound Guidance for Peripheral Venous Access: A Simplified Seldinger Technique

Asheville Surgery Center, Asheville, North Carolina. stonemd@charter.netOccasionally, patients for ambulatory surgery present with difficult peripheral venous access. Because only short-term access is needed, I prefer to avoid central venous cannulation and the associated risks. In these cases, I have begun using ultrasound guidance and a simplified Seldinger1technique for upper extremity peripheral venous access. A description of the technique and the results of a series of 10 procedures follows.In this technique, a tourniquet is applied to the upper arm. Alcohol or povidone iodine is used to prepare the antecubital fossa and distal upper arm. Disposable, nonsterile gloves are worn, and draping is unnecessary. A 10-5 MHz ultrasound probe (Sonosite Titan, L38; Sonosite, Bothell, WA) is covered with gel, an occlusive dressing (3M Tegaderm 10 × 12 cm; 3M, St. Paul, MN), and then additional sterile gel. Using a transverse view, an appropriate, nonthrombosed vein is identified. This may be the cephalic, basilic, or brachial vein. The brachial artery and median nerve are identified, so they can be avoided. Lidocaine is infiltrated 1–2 cm distal to the planned insertion site. I then use a spring-wire guide/catheter over needle assembly, usually used for arterial catheterization (Arrow arterial catheterization set FA-0420; Arrow International, Reading, PA). It consists of a 10.8-cm, 20-gauge catheter over a 22-gauge thin wall needle with an integral 0.46-mm-diameter spring wire guide. Using a transverse or longitudinal view and a free hand technique, the needle is inserted into the selected vein under real-time imaging. When ultrasound imaging shows the needle in the vein and venous blood flashback appears, I ask an assistant to advance the spring wire guide. Alternately, I drop the ultrasound probe and advance the wire myself. Next, the catheter is advanced over the wire, the tourniquet is released, and the needle/wire assembly is removed.Table 1shows the results of a series of 10 consecutive ultrasound-guided peripheral venous access procedures performed by the author. Patients were included in this series if at least two attempts at standard peripheral venous access failed or no adequate sized veins were visible or palpable in the upper extremity. Success was defined by the ultrasound view of the catheter in the vein and free flow of venous-appearing blood from the catheter. Each separate skin puncture was considered an attempt. Time was defined as the interval from initial skin puncture until success was achieved or the procedure was aborted. Nine of 10 catheter insertions were successful. There was an average of 1.3 attempts per procedure. The time required for a procedure averaged 140 s.Ultrasound guidance is used commonly for peripherally inserted central catheters2and occasionally for standard peripheral venous access. In emergency medicine applications, Keyes et al. 3found that a 5-cm catheter over needle infiltrated 8% of the time, and therefore, a longer catheter might be useful for these deeper veins. Sandhu and Sidhu4recommended long needle-mounted catheters or a Seldinger technique for deep veins. Using a guide wire may help to ensure that an advancing catheter enters the vein properly. However, a standard Seldinger technique takes more time and requires sterile gloves, draping, and a table to hold the wire, tissue dilator, and catheter.Ultrasound guidance for peripheral venous access may be improved by the use of a simplified Seldinger technique. The Arrow catheter set is commonly used for arterial catheterization, so anesthesiologists should be familiar with its use. The series described here demonstrates that this technique has a good success rate and the procedure takes a relatively short time to complete. Ultrasound guidance using this catheter may prevent multiple puncture attempts and decrease the use of unnecessary central venous catheters.Asheville Surgery Center, Asheville, North Carolina. stonemd@charter.net

Análisis coste-efectividad de dispositivos sanitarios diseñados para prevenir exposiciones percutáneas

Objective To assess the efficiency of the replacement of several medical devices by engineered sharp injury (SI) prevention devices (ESIPDs). Methods The cost-effectiveness ratios of the replacement of medical devices in use by ESIPDs were estimated: their purchasing costs and the direct costs of sharp injury care were taken into account; the number of SI avoidable by each ESIPD was estimated from the 252 occupational SI notified by healthcare workers at a 1,300 bed hospital from March 2002 to February 2003. The relationship between ESIPD additional costs and the number of high-risk SI was estimated (SI were classified as high-risk if they met two or more of the following criteria: moderately-deep or deep injury, injury with a device previously inserted in an artery or vein, or with a device exposed to blood). Results ESIPDs order according to cost-effectiveness ratio: safety needle for implanted ports (−2.65 €/SI avoided), followed by syringes with protective shield (869.79 €/SI), resheathable winged steel needles, needleless administration sets, and short catheters with protective encasement. ESIPDs order according to relationship between additional costs and number of high-risk sharp injuries avoided: safety needles for implanted ports, followed by winged steel needles, hypodermic syringes,short catheter and needleless administration sets. Conclusions Savings in SI care outweigh additional costs of certain ESIPDs. Cost-effectiveness analysis is useful in assigning priorities; however the risks of SI by every device must be taken into account.

Safety-engineered devices to prevent percutaneous injuries: cost-effectiveness analysis on prevention of high-risk exposure

OBJECTIVE To assess the efficiency of the replacement of several medical devices by engineered sharp injury (SI) prevention devices (ESIPDs). METHODS The cost-effectiveness ratios of the replacement of medical devices in use by ESIPDs were estimated: their purchasing costs and the direct costs of sharp injury care were taken into account; the number of SI avoidable by each ESIPD was estimated from the 252 occupational SI notified by healthcare workers at a 1,300 bed hospital from March 2002 to February 2003. The relationship between ESIPD additional costs and the number of high-risk SI was estimated (SI were classified as high-risk if they met two or more of the following criteria: moderately-deep or deep injury, injury with a device previously inserted in an artery or vein, or with a device exposed to blood). RESULTS ESIPDs order according to cost-effectiveness ratio: safety needle for implanted ports (-2.65 euro/SI avoided), followed by syringes with protective shield (869.79 euro/SI), resheathable winged steel needles, needleless administration sets, and short catheters with protective encasement. ESIPDs order according to relationship between additional costs and number of high-risk sharp injuries avoided: safety needles for implanted ports, followed by winged steel needles, hypodermic syringes, short catheter and needleless administration sets. CONCLUSIONS Savings in SI care outweigh additional costs of certain ESIPDs. Cost-effectiveness analysis is useful in assigning priorities; however the risks of SI by every device must be taken into account.

Evaluation eines ZVK-Komplett-Sets

Frequently central venous catheter sets do not contain all necessary materials. To evaluate, if combined measures using a specially arranged central venous catheter (CVC) set result in economical and clinical advantages, we compared both cost and time differences of a CVC complete set with ECG guide wire lead and an adhesive fixation with a standard set requiring additional materials, ECG fluid column lead and surgical suture. Furthermore, quality of different ECG leads, the reliability and tolerability of the adhesive fixation was compared. 76 elective adult surgical patients were randomly assigned to receive either a control CVC set or a test CVC complete set, which was featured by preconnected stopcocks, included sterile drapes, guide wire ECG position control, and an adhesive fixation. We performed ECG-guided placement of the central venous catheter using a guide wire lead in the test CVC set vs. fluid column lead in the control CVC set. Time was recorded for preparation phase of the nurse and the anesthetist, for the puncture phase, for the ECG position control and time for CVC fixation. Quality of ECG position control using guide wire or fluid column was determined by forming Pmax/R ratio. Costs of the complete set and the standard set with additional material were compared. Times for preparation of nurse and anesthetists, for ECG position control and catheter fixation were significantly shorter using the test catheter set and resulted in a total time saving of 6 min (P < 0.01). Times for sterile preparation and central venous puncture were not significantly different between the groups. ECG position control using the guide wire was successful in 37 out of 38 patients (97%) and in 34 of 38 patients (89%), respectively. Pmax/R ratio was 0.8 +/- 0.2 using the guide wire versus 0.5 +/- 0.2, respectively. There were only 2 out of 38 adhesive fixations, that had to be replaced, while the mean duration of adhesive fixation was 6.2 days (3-15 days). Avoidance of disposable materials in the test CVC set led to a significant reduction of costs compared to the control CVC set. The test CVC complete set allows a significant time saving and cost reduction in performing a central venous catheter line because of completely included disposable materials. CVC position control via guide wire needs less time and shows significantly better quality of ECG compared to fluid column ECG lead. An adhesive revealed to be a reliable CVC fixation comparable to a surgical suture.

Incorrectly assembled nerve block catheter sets

Incorrectly assembled nerve block catheter sets

The T-Tube Approach to Biliary Strictures in Liver Transplant Recipients

Nonanastomotic biliary strictures (BS) are challenging complications of liver transplantation (LT) with long-term patency rates of 25% after nonsurgical treatment (1, 2). We report on a novel approach in the management of early-onset, nonanastomotic BS by means of a radiology-assisted T-tube approach. This technique was employed in a LT recipient with a severe right hepatic duct stricture three months after LT. A 52-year-old male patient was transplanted for HCV-related cirrhosis with an ABO-compatible, 50-year-old cadaver graft. Cold ischemia time was 9h10′ and biliary reconstruction was over a T-tube (3). Three months after LT the patient was admitted to the hospital for the scheduled T-tube removal (3). His liver function tests (LFT) were elevated (total bilirubin 2.1 mg/dL; GGT 68 IU/L; alkaline phosphatases 337 UI/L), but no hepatic artery thrombosis was detected on Duplex US scan. On trans-tube cholangiography a severe stricture of the right hepatic bile duct was observed in close proximity to the biliary confluence and associated with a mild dilation of the left biliary duct (Fig. 1). Under fluoro-angiographic control, a hydrophilic, 150-cm long, 0.035′ guide wire with a 3-cm flexible tip (Terumo Radiofrequency Guide Wire M, Radiofocus, Terumo Europe, Leuven, Belgium) was introduced in the T-tube and oriented through its ascending branch up to the distal aspect of the stricture. The T-tube was removed and a 6-Fr dilator (Fascial Dilator, MediTech, Boston Scientific Corporation, Watertown, MA) was passed through the stricture. The flexible guide wire was removed and replaced with a PTFE-shafted, 145-cm long, 0.035′ stiff one (Amplatz Super Stiff, MediTech, Boston Scientific Corporation, Miami, FL). Cone-tipped dilators up to 10-Fr diameter were passed over the stiff wire to dilate the strictured duct. A hydrophilic, 8-Fr catheter (Flexima Regular APD All Purpose Drainage Catheter Set, MediTech, Boston Scientific Corporation, Watertown, MA) was placed with drainage holes on either side of stenosis (Fig. 2). The catheter was secured to the skin and left open for 12 hr. A control US scan 24 hr later confirmed proper placement of the catheter and the patient was dismissed 48 hr after the procedure. He was readmitted 1 month later for a scheduled cholangiography and the 8-Fr catheter was replaced by a 10-Fr one with no complications. This latter catheter was left in place for 1 month and removed under cholangiographic control. A magnetic-resonance cholangiography performed 1 month after stent removal did not disclose any stricture of the biliary tree and LFTs had returned to baseline. At a follow-up of 9 months post-LT the patient is alive without clinically evident relapse.FIGURE 1.: T-tube cholangiography showing a severe stricture of the right hepatic duct above the confluence and associated with a mild dilation of the left hepatic duct.FIGURE 2.: Percutaneous cholangiography showing proper positioning of the 8-Fr stent catheter.BS affect 9% to 15% of adult LT patients and their management varies according to type, location, and length of lesions and the availability of experienced radiologic or endoscopic teams (1, 2, 4). A recent survey reported that 67% of US centers favor the endoscopic or percutaneous approach with 2-year patency rates in excess of 70% (5). Nonsurgical management of nonanastomotic BS requires multiple interventions and yields patency rates of approximately 25% in the long term (1, 2, 4, 5). Better resultsare reported for early, extrahepatic, single strictures, and those not associated with ductopenic rejection or hepatic artery thrombosis (1, 2, 4, 5). The T-tube approach may represent a valid alternative in the management of early-onset, proximally-sited BS, as it spares patients rendezvous techniques, and larger series are strongly favored to validate its results in the long term. Paolo De Simone Lucio Urbani Luca Morelli Gabriele Catalano Laura Coletti Marcello Spampinato Franco Filipponi Liver Transplant Unit University of Pisa Cisanello Hospital Pisa, Italy Alessandro Campatelli General Surgery and Transplant Department University of Pisa Cisanello Hospital Pisa, Italy

Kavafilter - gibt es eine Indikation zur Implantation?

The indication of vena cava filter implantation is controversially discussed. On the basis of the available literature and our own results a critical analysis of this issue is given. Between 1994 and 2003, we inserted a total of 29 vena cava filters; 24 temporary and 5 permanent filters. In twelve patients, the placement of the filter was indicated due to pulmonary embolism and a contra-indication to dose adjusted heparin therapy. Seven additional patients experienced a recurrent pulmonary embolism despite adequate heparin therapy. An additional prophylactic filter insertion was carried out in ten patients. The temporary vena cava filters were left in place between 7 to 38 days with an average of 17 days. Total implantation time of temporary filters was scheduled until complete mobilisation of the patients, generally in conjunction with an effective dosage of oral anticoagulants. No patient died in connection with the insertion of the filter and no further pulmonary embolisms occurred. One case of inferior vena cava thrombosis occurred in each group of temporary and permanent filters. In one third of the removed filter systems, thrombi in the filter were found. Local infections of the catheter and introducer sets were observed in two patients. Moreover, in one case the strut of a temporary filter broke and subsequently dislocated 17 days after insertion. However, there is little evidence concerning vena cava filters, and further investigations are necessary. Until additional data are available, filters should generally be restricted to patients with deep venous thrombosis and pulmonary embolism who cannot receive anticoagulation, and highly selected cases.

Fallopian Tube Occlusion with Use of a Small Intestine Submucosa Device: Evaluation in a Rabbit Model

The present study evaluates the short- and midterm efficacy of a small intestinal submucosa (SIS) device for fallopian tube occlusion in rabbits. In a pilot study, several SIS device designs were tested for positional stability (absence of migration). The design selected for further testing consisted of a center of spongy SIS surrounded by an SIS sheet and held together by a 0.006-inch wire helix with two barbs. It was delivered on the tip of a short coaxial 3-F/5-F catheter set. Using this design, bilateral transuterine fallopian tube occlusion was performed in eight New Zealand White rabbits. Follow-up consisted of plain radiography at 2 weeks and hysterosalpingography at 6 weeks (n = 4 animals; eight tubes), 12 weeks (n = 2 animals; four tubes), or 24 weeks (n = 2 animals; four tubes). Thereafter, the animals were killed and the fallopian tubes were harvested for histologic evaluation. A single device was placed successfully in each fallopian tube. Fifteen of 16 devices (94%) remained in place throughout follow-up. One device migrated into the vagina at 2-week follow-up. Hysterosalpingography of the 15 tubes with occluders in place showed occlusion in seven of seven (100%) at 6 weeks, three of four (75%) at 12 weeks, and two of four (50%) at 24 weeks. Histologic evaluation revealed luminal occlusion by reorganized SIS containing macrophages, fibrocytes, and scant foreign-body giant cells. Only a mild inflammatory reaction was observed around the tube. In the animals with recanalization at 12 and 24 weeks, new channels were found alongside the original still-occluded fallopian tube lumen. The original lumen of the fallopian tube was effectively occluded by the SIS occluder, which was remodeled within the fallopian tubes of rabbits. Partial peripheral recanalization was observed over time.

Cathéter lombaire par voie postérieure : échec technique lié au matériel

The undeniable postoperative analgesia brought by the lumbar plexus block among patients scheduled for major surgery of the hip or knee justifies, the setting of a catheter to allow a continues analgesia more durable. Having drawn aside the difficulties of the daily practice (in allusion to the number of blocks carried out per day) and anatomical variations, the failure of the perineural catheter setting is in direct relationship with the material used by the anaesthesiologists for neurostimulation. The presentation of a case report describes a failure of catheter introduction due to the canula in deep continuous blocks, and the advantages and disadvantages of the various sets of neurostimulation. The authors conclude that the sets with the “catheter through the needle” are to be recommended, particularly the stimulating Tuohy needle.

Models for neuro-oncological preclinical studies: solid orthotopic and heterotopic grafts of human gliomas into nude mice

To study the optimum therapeutic modalities for treating human malignant brain tumors in vivo without ethical limitations, a model of heterotopic and another of orthotopic xenografting into nude mice were developed. For the first implantation, 11 human high-grade gliomas and 4 low-grade tumors were microsurgically grafted on epigastric vessels. The 11 high-grade gliomas, but no low-grade tumors, were established into nude mice. Afterwards, all these mouse-adapted gliomas which grafted into other nude mice developed. Introduction of a microcatheter into the femoral artery or vein permitted infusion for magnetic resonance imaging (MRI) and treatment. A bladder catheter setting and electrode implantation allowed urine sampling and ECG or EEG recording. Thus, the most important parameters of chemo- and radiotherapy to destroy a maximum number of malignant cells or to inhibit their divisions and the hosts reactions to treatment can be studied. The human gliomas transplanted onto the mouse brain infiltrated the host brain at great distances from the tumor, as in human patients. So, this second implantation constitutes a representative model of the evolution of human gliomas, and allows the study of malignant cell migration in the brain before, during and after treatment determined with the heterotopic model and to appreciate the tolerance of the colonized brain to these treatments. Echography and MRI allowed us to follow the macroscopic evolution with or without treatment of the malignant brain tumors transplanted onto mouse brains. It should now be possible to undertake the same clinical studies on patients after appropriate consideration of ethical and scientific constraints.