Single Lumen Research Articles

713. Vancomycin Heteroresistance in Coagulase Negative Staphylococci (CoNS) Causing Central Line-Associated Bloodstream Infection (CLABSI) in Pediatric Patients with Leukemia

BackgroundHeteroresistance to vancomycin in Staphylococcus aureus may be associated with poor response to therapy. Although CoNS are the most important CLABSI pathogens in children with leukemia, and treatment failure is common, little is known about the frequency or clinical significance of heteroresistance. This is a retrospective study to evaluate frequency, risk factors and clinical impact of heteroresistance in CoNS CLABSI in immunocompromised children.MethodsThe study was approved by the Institutional Review Board. All patients undergoing treatment for leukemia at St. Jude Children’s Research Hospital with CoNS isolated from blood between 2010 and 2016 were eligible. The first available isolate from each blood culture episode was obtained from the clinical laboratory and tested for vancomycin heteroresistance by population analysis profiling in comparison to the hVISA strain Mu3. Clinical data were collected from the medical record for up to 9 months after the episode. Episodes with ≥2 positive cultures or a single positive culture from a single lumen CVC were classified as CLABSI. Outcomes of interest included treatment failure (death or relapse of infection) or poor response to vancomycin therapy (persistence of bacteremia ≥1 day after initiation of vancomycin or treatment failure). Logistic regression was used to test associations between heteroresistance and exposures, and cumulative incidence analyses were used to test the effect on outcomes.ResultsA total of 74 CoNS isolates were obtained from 65 participants, 39 with ALL and 26 with AML; 25/74 (33.8%) of isolates showed showed heteroresistance. The strongest identified risk factor for infection with a heteroresistant organism was number of days of vancomycin in the preceding 60 days (OR = 1.05/day; P = 0.035). In the 40 CLABSI episodes, heteroresistant isolates had a higher cumulative incidence of poor response and of treatment failure (P = 0.006 and P = 0.003, respectively).ConclusionVancomycin heteroresistance is common in CoNS causing CLABSI in children undergoing treatment for leukemia, and is associated with an increased risk of Treatment Failure. Further research should aim to validate this finding in an independent cohort and identify strategies to improve the diagnosis and treatment of these infections.Disclosures R. Hayden, Roche Molecular: Scientific Advisor, Consulting fee. Abbott Molecular: Scientific Advisor, Consulting fee. Quidel: Scientific Advisor, Consulting fee. J. Wolf, Karius Inc.: Investigator, Research support.

Improving a better nurse practice associated with the manipulation of CVC and needleless connectors

Background: With the increase in the number, frequency and duration of treatments, long-term catheters were needed to allow different and continuous administration of intravenous therapy, transfusion support and blood sampling. Since many years, the use of needleless connectors is recommended on central-lines access, being crucial the knowledge of the implications associated with the use of these long terms central venous catheters (CVC). Purpose: This study aims the improvement of the CVC management, using a double lumen extension line with needleless connectors, in acute leukemia (AL) patients population undergoing high dose chemotherapy treatments. Methods: A single-centre, prospective comparative study was performed, including all consecutive AL patients using a long-term double lumen silicone CVC (commonly named Hickman® type), with single access (group 1) or double lumen extension with needleless connectors (group 2), undergoing chemotherapy treatment (CT) or aplasia support from December 2014 to December 2016 at the Haematology Department of the Portuguese Institute of Oncology of Porto. Results: Overall 17 AL patients reporting 78 hospital admissions [median 4, range 1 to 12], 1.122 admission days [median of 12.5, range 3 to 44] and 1.044 cvc-days [median 12, range 3 to 35] were studied. Considering the central line reports, no significant CLABSI risk was determined between study groups [RR 0.4528, 95 % CI, 0.1235-1.6605], however, the central line colonization was always reported in the SSNC group. All positive blood cultures were reported undergoing neutropenia. None CRBSI was identified. Conclusion: The study suggests that the DSNC can be a good option to the nursing practice that aims the reduction of the central line colonization risk and improves a safety CVC management in AL patients undergoing high dose chemotherapy.

Evaluation of efficacy of Arndt endobronchial blocker for airway management during one-lung ventilation in pediatric patients

Objective To evaluate the efficacy of Arndt endobronchial blocker (AEB) for airway management during one-lung ventilation(OLV) in pediatric patients. Methods Thirty pediatric patients, aged 4 months-12 yr, weighing 5.6-26.0 kg, of American Society of Anesthesiologists physical status Ⅱ-Ⅳ, scheduled for elective thoracotomy under OLV requiring the use of single lumen tracheal tube assisted by AEB, were enrolled in this study.OLV was performed with the AEB placed outside the single lumen tracheal tube in pediatric patients below 2 years old and with AEB inserted through the single lumen tracheal tube in pediatric patients ≥ 2 years old.The rate of successful establishment of artificial airway at first attempt, time of establishing artificial airway, time of pulmonary collapse, AEB malpositions and airway pressure before and after OLV were recorded, and the efficacy of lung collapse was evaluated. Results The rate of successful tracheal intubation of extraluminal and endoluminal AEB placement at first attempt was 100% in 30 pediatric patients, and no high airway pressure was found after OLV.The efficacy of lung collapse was poor in one patient and good in one patient, and intraoperative AEB malpositions were found in two patients among the pediatric patients used extraluminal AEB placement.The efficacy of lung collapse was good in one patient, intraoperative AEB malposition was found in one patient, and SpO2 was decreased after OLV in one patient among the pediatric patients used endoluminal AEB placement. Conclusion Reasonably selecting the method of placing AEB followed by enhancing intraoperative airway management can be safely and effectively applied for OLV in pediatric patients. Key words: Intubation, intratracheal; Respiration, artificial; Child

Less Lumens‐Less Risk: A Pilot Intervention to Increase the Use of Single‐Lumen Peripherally Inserted Central Catheters

To reduce risk of complications, existing guidelines recommend use of peripherally inserted central catheters (PICCs) with the minimal number of lumens. This recommendation, however, is difficult to implement in practice. We conducted a pilot study to increase the use of single-lumen PICCs in hospitalized patients. The intervention included (1) education for physicians, pharmacists, and nurses; (2) changes to the electronic PICC order-set that set single lumen PICCs as default; and (3) criteria defining when use of multilumen PICCs is appropriate. The intervention was supported by real-time monitoring and feedback. Among 226 consecutive PICCs, 64.7% of preintervention devices were single lumen versus 93.6% postintervention (P < .001). The proportion of PICCs with an inappropriate number of lumens decreased from 25.6% preintervention to 2.2% postintervention (P < .001). No cases suggesting inadequate venous access or orders for the placement of a second PICC were observed. Implementing a single-lumen PICC default and providing education and indications for multilumen devices improved PICC appropriateness.

Long-term survival in six cats with mediastinal cysts.

Mediastinal cysts were diagnosed as incidental findings in six cats evaluated for non-thoracic disease, including staging for historical bladder leiomyosarcoma, flea dermatitis and hairballs, and hyperthyroidism. Radiographically, the cysts appeared as soft tissue opacities cranial to the heart. Ultrasound revealed the masses to be thin-walled, single lumen, anechoic, fluid-filled structures. One cat also had thoracic and abdominal CT performed for cancer staging; the CT revealed a well-defined, fluid-attenuating mass without peripheral contrast enhancement in the cranial mediastinum. Fine-needle aspiration confirmed acellular fluid consistent with a cyst in five cases; in one case the cyst ruptured during aspiration and no fluid was obtained. Post-aspiration, all masses were no longer visible with ultrasound or radiographs. No treatment was recommended for the cysts. Long-term follow-up (2-9 years post-diagnosis) was available in all six cats. The cysts recurred in five cats but were never associated with clinical signs. Mediastinal cysts are an important benign differential for cranial mediastinal masses in cats. Treatment for the cysts does not appear to be indicated. This series also includes the first CT description of this clinical entity.

The first uniportal video-assisted thoracoscopic surgery masterclass in New Zealand

Although thoracotomy is still a standard approach to lung resection for some New Zealand (NZ) surgeons, there is an increasing penetration of video-assisted thoracoscopic surgery (VATS) approaches to complex lung resection, but only a few surgeons have applied uniportal techniques. This paper describes the first uniportal VATS (uVATS) Masterclass held in NZ that includes an animal wetlab, and a 2-day live surgery with proctorship from Professor Diego Gonzalez-Rivas. In our wetlab experience, we have used single lumen endotracheal intubation and bronchial blocker to facilitate excellent lung isolation. Prof Gonzalez-Rivas proctored 6 live surgical cases of successful uVATS for lung resection without compromising the optimal oncological principles. Following this Masterclass, our unit has adopted uniportal VATS as the default approach for all lung resection and pleural based operations.

Uniportal VATS in porcine specimens using single lumen endotracheal intubation and bronchial blocker

Uniportal VATS in porcine specimens using single lumen endotracheal intubation and bronchial blocker

Perioperative anesthetic management of children with congenital central hypoventilation syndrome and rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation undergoing thoracoscopic phrenic nerve-diaphragm pacemaker implantation.

Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation are rare neurocristopathies characterized by autonomic dysregulation including bradyarrhythmias, abnormal temperature control, and most significantly, abnormal control of breathing leading to tracheostomy and ventilator dependence as life support. Surgical advancements have made phrenic nerve-diaphragm pacemakers available, to eliminate the tether to a mechanical ventilator for 12-15hours each day. The thoracoscopic approach to implantation has allowed for a less invasive approach which may have implications for pain control and recovery time. However, thoracoscopic implantation of these devices presents several challenges to the anesthesiologist in these complex ventilator-dependent patients, including, but not limited to, sequential lung isolation, prevention of hypothermia, and management of arrhythmias. Postoperative challenges may also include strategies to treat hemodynamic instability, managing the ventilator following lung derecruitment, and providing adequate pain control. We aimed to describe the anesthetic management of Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation patients undergoing thoracoscopic phrenic nerve-diaphragm pacemaker implantation and the nature and incidence of perioperative complications. A retrospective chart review was performed of 14 children with Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation undergoing phrenic nerve-diaphragm pacemaker implantation at a single academic pediatric hospital between 2009 and 2017. Demographic information, intraoperative management, and perioperative complications were analyzed from patient records. Twelve of 14 patients (86%) underwent an inhalational induction via tracheostomy. Lung isolation was achieved via fiberoptic guidance of a single lumen endotracheal tube sequentially into the right or left mainstem bronchi for 12 patients (86%). Double lumen endotracheal tubes were utilized in two patients (7%) and bronchial blockers in two patients (7%) for lung isolation. Anesthesia was maintained using a balanced technique of volatile agents (sevoflurane/isoflurane) and opioids (fentanyl). Bradyarrhythmias developed in six patients (43%) during surgery, 5 (36%) responded to anticholinergics and one patient (7%) required backup cardiac pacing using a previously implanted bipolar cardiac pacemaker. Intraoperative hypothermia (<35.5°C) was present in five patients (36%) despite the use of warming devices. Hypercarbia (>50mmHg) during lung isolation was present in eight patients (57%) and hemoglobin desaturation (<90%) in four patients (29%). Postoperatively, oxygen desaturation was a common complication with nine patients (64%) requiring supplemental oxygen administration via mechanical ventilator or manual bag ventilation. Opioids via patient-controlled analgesia devices (12 patients, 86%) or intermittent injection (two patients, 14%) were administered to all patients for postoperative pain control. Phrenic nerve-diaphragm pacemaker placement was successful thoracoscopically in all patients with no perioperative mortality. The main anesthetic challenges in patients with Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation include hemodynamic instability, the propensity to develop hypothermia, hypercarbia/hypoxemia, and the need to perform bilateral sequential lung isolation requisite to the thoracoscopic implantation technique. Most anesthetic agents can be used safely in these patients; however, adequate knowledge of the susceptibility to complications, coupled with adequate preparation and understanding of the innate disease characteristics, are necessary to treat anticipated complications.

PS02.017: EFFICACY OF INTRAOPERATIVE RECURRENT LARYNGEAL NERVE MONITORING DURING UPPER MEDIASTINAL LYMPH NODE DISSECTION IN THORACOSCOPIC RADICAL ESOPHAGECTOMY

Abstract Background The development of minimally invasive surgery has yielded many benefits, therefore the number of patients undergoing thoracoscopic radical esophagectomy (TRE) for esophageal cancer has been increasing worldwide. However, in the Japanese nationwide web-based database report, the incidence of recurrent laryngeal nerve (RLN) paralysis and overall morbidity were significantly higher in the TRE group than in the open esophagectomy group. In recent years, intraoperative nerve monitoring (IONM) is commonly being used in thyroid and parathyroid surgery in many centers. We tried to determine the feasibility and effectiveness of IONM of RLN during upper mediastinal lymph node dissection in TRE. Methods All 628 patients who underwent TRE in the left lateral decubitus position at Osaka City University Hospital between May 1995 and February 2018 were enrolled in the present study. We introduced IONM using NIM® (Medtronic) during TRE from October 2016 at our hospital. We divided retrospectively the patients into two groups: IONM group (TRE with IONM of RLN; n = 49) and No-IONM group (TRE without IONM of RLN; n = 579). Diagnosis of RLN paralysis was performed using laryngoscopy. The feasibility of IONM during TRE and the incidence of postoperative RLN paralysis were compared with those in No-IONM group. Results IONM could be performed for 46 patients (93.9%) in IONM group. Three patients (6.1%) could not keep single-lung ventilation using a single lumen tracheal tube with a bronchial blocker and needed to replace a tracheal tube by a double lumen tube during TRE. The incidence of postoperative RLN paralysis (CD≧ 1; CD; Clavien-Dindo classification of surgical complications) was 17.4% in IONM group and 30.2% in No- IONM group. There was a significant difference in the incidence of postoperative RLN paralysis (P &lt; 0.05). Moreover, the right and bilateral paralysis of RLN after TRE did not occur in any patients in IONM group. Conclusion IONM of RLN during TRE is technically feasible. The introduction of standardized IONM of RLN during TRE is able to reduce the incidence of postoperative RLN paralysis. Disclosure All authors have declared no conflicts of interest.

One-lung ventilation in a patient with a large mass on the glottis

Rationale:One-lung ventilation (OLV) is required during most thoracic surgeries to facilitate surgical visualization by collapsing the lung. Double-lumen tubes and bronchial blockers are two commonly used devices for OLV; however, it may be difficult to place two devices in patients with narrow inlets, such as those that have tumor-induced airway stenosis.Patient concerns:We report the case of an adult patient with a lung tumor that was growing rapidly and hemorrhaging; thus, a thoracotomy for lung resection should have been performed as early as possible. However, a large mass on the glottis obstructed the entry of the double-lumen tube or bronchial blocker. Therefore, the operation could not be performed because of the inability to provide one-lung ventilation via the conventional intubation method.Diagnoses:Computed tomography (CT) revealed a lung tumor that was growing rapidly and preoperative bronchoscopy showed a large mass on the vocal cords.Interventions:After anesthesia induction, a Uniblocker and a small single lumen tube were intubated and the Uniblocker was inserted extraluminally of the single lumen tube. One-lung ventilation was achieved successfully in this patient.Outcomes:The surgery proceeded uneventfully for 4 hours without any complications.Lessons:Extraluminal use of the Uniblocker and a small single lumen tube may be recommended for patients receiving OLV and who have narrow inlets, especially under emergency situations.

VS03.08: ANASTOMOTIC TECHNIQUES FOR MINIMALLY INVASIVE TRANSTHORACIC ESOPHAGECTOMY

Abstract Description Minimally invasive esophagectomy has the potential to reduce the incidence of pulmonary complications and postoperative pain. This video shows two safe and reproducible technical variants for thoracoscopic stapled anastomosis. The patient is placed in a left semi-prone position after induction of anesthesia with a single lumen orotracheal tube. Triportal access and low-pressure pneumothorax (8 mmHg) are used for the procedure. Once circumferential mobilization of the esophagus is completed, intraoperative ultrasonography is performed to identify a previously placed endoscopic metal clip marking the upper tumor level. The esophagus is safely transected above this level. An end-to-side intra-corporeal esophagogastric anastomosis is performed. Technique A. The esophagus is stapled with a 60 mm cartridge (EndoGIA™ Tri-Staple™ purple). The anvil of a 25 mm circular stapler (OrVil™) is inserted transorally and retrieved through a small hole in the esophageal stump. Technique B. The 25 mm anvil is inserted through a transverse esophagotomy with a 7 cm long 2–0 polypropylene suture attached to the sharp tip. The suture is passed from inside to outside of the esophageal lumen. The esophagus is then divided distal to the anvil with an linear stapler. At this point, the anvil is pulled out with a gentle traction close to the stapled line. In both techniques, the circular stapler is introduced into the chest cavity through a mini-thoracotomy at the level of lowermost trocar and a wound retractor (Alexis™) is used. The head of the circular stapler, sealed with a surgical glove cutted at the middle finger, is then introduced into the gastric tube through a small gastrotomy on the lesser curvature. The tip of the gastric tube is perforated close to the greater curvature and engage the esophageal anvil. After checking the doughnut, transection of the remnant gastric tube is completed with a linear stapler and the specimen is retrieved through the mini-thoracotomy. Disclosure All authors have declared no conflicts of interest.

Outcome of endoscopic small-bore naso-jejunal tube stenting in early postoperative jejunal limb obstruction after gastrectomy.

Early postoperative jejunal limb obstruction is a rare complication following gastric surgery with jejunal reconstruction. The condition is mainly attributed to kinking of the jejunal limbs, gastrojejunal or jejunojejunal anastomosis. There has been currently limited information regarding the safety and efficacy of endoscopic treatment in patients with early postoperative jejunal obstruction. We aimed to investigate outcome of endoscopic small-bore naso-jejunal (N-J) tube stenting across the obstructed segment in patients with uncomplicated early postoperative partial jejunal limb obstruction. All patients diagnosed of jejunal limb obstruction within 8 weeks after gastric-related surgery were reviewed. Patients with malignant obstruction, complete closed loop obstruction, sepsis, instability, intestinal strangulation, or perforation were excluded. All patients underwent endoscopic dekinking and stenting for 2 weeks with an N-J tube using 16-French single lumen plastic nasogastric tube across the obstruction segment after failed conservative therapy. Successful N-J tube placement across the obstruction point was confirmed by contrast study. Complications, technical, and clinical success were evaluated. Twenty-one patients met the criteria. The primary operations were 7 partial gastrectomies with Billroth-II reconstruction, 7 total or partial gastrectomies with Roux-en-Y reconstruction and 4 Whipple's operations, 2 bypass procedures, and 1 proximal gastrectomy. Most common site of obstruction was jejunojejunal anastomosis and gastrojejunal anastomosis following Roux-en-Y and Billroth-II reconstruction, respectively. Endoscopic N-J tube placement was technically successful in 20 out of 21 patients (95%). One patient had aspirated pneumonia. There was no procedure-related mortality. After N-J tube removal, clinical success was demonstrated in 19 out of 20 patients (95%) at the median duration of 6 months. One patient underwent reoperation due to repeated tube dislodgement. Endoscopic stenting with a 16-F naso-jejunal tube across the angulated segment is safe and effective for treatment of patients with uncomplicated early postoperative partial jejunal limb obstruction following gastric surgery with jejunal reconstruction.

Modified Peritoneal Dialysis for Treatment of Acute Renal Failure after Complex Congenital Heart Surgery in Infants

Acute kidney injury (AKI) is one of the common complications in infants and children after complex congenital heart surgery. Peritoneal dialysis (PD) is usually applied for renal replacement therapy (RRT), especially in infants. We investigated the efficacy and safety of modified PD for the treatment of acute renal failure and congestive heart failure after cardiac surgery for congenital heart disease in infants. We retrospectively analyzed five consecutive patients from October 2015 to February 2017. The patients were aged from four days to five years old, and all had acute renal failure and congestive heart failure after cardiac surgery. In the five patients treated with modified PD (five males; average weight: 11.2 ± 5.5 kg), we used the Seldinger technique percutaneous abdominal puncture 16 G single lumen central venous catheter instead of the Tenckhoff peritoneal dialysis catheter as a PD catheter. Modified PD was intermittent. We recorded and monitored circulation and metabolism index. Five cases (100%) with modified PD were restored to normal renal function. Congestive heart failure was gradually alleviated, and pulmonary and cardiovascular function were improved. Urine volume increased. Neither peritonitis nor catheter leakage occured in any of our cases. Urine volume increased due to PD, from 0.16 + 0.18 mL/kg*h before PD to 2.63 + 1.05 ml/kg*h at the end of PD (P < .05). Serum creatinine, serum urea nitrogen, and serum K+ changed from 85.0 ± 36.5 μmol/L, 17.1 ± 7.5 mmol/L, and 4.57 ± 0.30 mmol/L before PD, to 76.0 ± 36.7 μmol/L, 20.1 ± 11.0 mmol/L, and 4.42 ± 0.42 mmol/L at the end of PD, respectively (P > .05). Acidosis, hyperkalemia, hypoxemia and low cardiac output syndrome were improved. All patients were cured and discharged with normal renal function. We conclude that modified single lumen central venous catheter for PD is a safe, feasible, and less invasive therapeutic strategy for AKI in infants undergoing cardiac surgery, and is worthy of being widely applied in clinical practice.

Adjustable and Rigid Fixation of Brain Tissue Oxygenation Probe (Licox) in Neurosurgery: From Bench to Bedside

Multimodal neuromonitoring has become a fundamental part of management for many neurosurgical disorders such as subarachnoid hemorrhage and severe traumatic brain injury. Brain tissue oxygen tension monitoring requires insertion of a probe into the brain parenchyma through a single multiple lumen bolt, or in a subcutaneously tunneled fashion. As those patients often require early magnetic resonance imaging, typically using bolts is disadvantageous due to massive metal artifact. Similarly, subcutaneous tunneling is often problematic as suture fixation can loosen over time. We hereby report a new method of fixation of the Licox brain tissue oxygenation probe with 1 or 2 3-way taps that are attached to a standard plastic cannula, resulting in a stable connection with no need for further direct sutures around the probe and above all with no metal artifacts, which negates magnetic resonance imaging. The extended fixation system was first tested with cardiopulmonary resuscitation in a brain injured porcine model. It was thereafter adopted in our daily clinical practice.

Monitoring voltage fluctuations of intracellular membranes

In eukaryotic cells, the endoplasmic reticulum (ER) is the largest continuous membrane-enclosed network which surrounds a single lumen. Using a new genetically encoded voltage indicator (GEVI), we applied the patch clamp technique to cultured HEK293 cells and neurons and found that there is a very fast electrical interaction between the plasma membrane and internal membrane(s). This discovery suggests a novel mechanism for interaction between the external membrane and internal membranes as well as mechanisms for interactions between the various internal membranes. The ER may transfer electrical signals between the plasma membrane and other internal organelles. The internal membrane optical signal is reversed in polarity but has a time course similar to that of the plasma membrane signal. The optical signal of the GEVI in the plasma membrane is consistent from trial to trial. However, the internal signal decreases in size with repeated trials suggesting that the electrical coupling is degrading and/or the resistance of the internal membrane is decaying.

Novel Mouse Model of a Human Mutation in NKCC1 Confirms its Mistargeting in Epithelia

A 15‐year old patient with complete gastrointestinal and bladder failure, endocrine insufficiencies, and orthostatic intolerance carries a de novo mutation in SLC12A2, the gene encoding the Na‐K‐2Cl cotransporter‐1 or NKCC1. The 11 bp deletion leads to truncation of the cytosolic COOH‐terminal tail of the cotransporter making it non‐functional. Expression of the mutant transporter increases the amount of dimerization, suggesting the possibility that the mutant transporter might exert dominant‐negative effects on the wild‐type transporter. In polarized MDCK cells grown on permeable filters or in 3‐D culture cysts, most of the mutant transporter signal is observed on the apical membrane, in contrast to the basolateral expression of wild‐type cotransporter. The mutant transporter affects the formation of MDCK cysts, as we observed the presence of multiple lumens, as opposed to single lumen formation with wild‐type cells. The mutant transporter also causes trafficking of the wild‐type cotransporter to the apical membrane.To assess the relevance of this observation in vivo, we created a mouse model that recapitulates the human mutation. Using CRISPR/cas9, a guide RNA that targets cas9 to exon 22 of the Slc12a2 gene, and a repair oligonucleotide that deletes 11 bp from the exon, we successfully generated a female founder animal that carried the designed mutant allele in addition to a non‐homologous end joining mutation in the second allele. After one backcross that segregated the two alleles, the line was further established by backcrossing for 2 additional generations in C57BL/6J. This mouse now carries the 11 bp deletion mutant allele and a wild‐type allele. We examined the expression of NKCC1 in the salivary gland and the intestine, two Cl− secreting epithelia where the wild‐type cotransporter is typically expressed on the basolateral membrane. In both tissues, intense apical staining was observed, confirming the data obtained with MDCK cells. Preliminary studies indicate that the mouse has no overt adverse phenotype, although the mouse lives in a pathogen‐free barrier facility and has not been challenged.In conclusion, our data demonstrate that expression of a truncated Na‐K‐2Cl cotransporter causes mistargeting of the wild‐type cotransporter to the apical membrane of Cl− secreting epithelia and affects proper lumen formation in MDCK cysts. These observations may explain the multisystem dysfunction that is observed in the patient.Support or Funding InformationSupported by NIH grants R21GM118944 and 1RO1DK093501.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Obtaining central access in challenging pediatric patients.

Central catheter placement is one of the most commonly performed procedures by pediatric surgeons. Here, we present a case series of patients where central access was obtained at our institution with the utilization of a novel ultrasound-guided technique. This series represents the first of its kind where the native, parent vessels were inaccessible, resulting in a challenging situation for providers. A retrospective chart review was performed in pediatric patients (0-17years) at a tertiary care institution between July 2012 and November 2017 on all central line procedures where ultrasound was utilized to cannulate the brachiocephalic or superior vena cava in face of proximal occlusion. Our group has previous experience utilizing an image-guided in-plane approach to central line placement in the pediatric population. Demographics, operative characteristics, and postoperative complications were reviewed. A total of 11 procedures were included in this case series where the BC (N = 9) or SVC (N = 2) were cannulated for access. Internal jugular vein cannulation was attempted on each patient unless preoperative imaging demonstrated occlusion. The median operative time was 43 ± 23min. Most procedures were performed on the right sided (63%), with catheters ranging from 4.2F single lumen to 14F double lumen. Since being placed, three (27%) catheters have been removed, with one due to non-use, one due to sepsis, and the final one due to malposition. With the continued need for long-term central access in the pediatric population, distal vein occlusion or inaccessibility can prove challenging when attempting to obtain central access. Here, demonstrated a safe alternative technique that provides an additional option in the pediatric surgeon's armamentarium for patients with difficult central access.

Pulmonary Artery Rupture Management with a Single Lumen Endotracheal Tube: Old Tricks that Should be Revisited

Patient: Female, 67Final Diagnosis: Pulmonary artery ruptureSymptoms: Hemoptysis • shortness of breathMedication: —Clinical Procedure: Ventricular assist deviceSpecialty: Cardiac SurgeryObjective:Unusual clinical courseBackground:Pulmonary artery rupture can be a lethal complication of a pulmonary artery catheter (PAC). Different techniques have been used to manage PAC-induced pulmonary artery rupture, including double lumen endotracheal tube (DLT), bronchial blockers, pulmonary artery embolization, thoracotomy with hematoma evacuation, and extracorporeal life support for ventilation (ECLS). Single lumen endotracheal tube (ETT) is not frequently reported in the literature despite its advantages.Case Report:The authors present a case of PAC-induced pulmonary artery rupture successfully managed with a single lumen ETT. Although single lumen ETT is more labor intensive and requires constant critical care attention, the advantages of this technique are reported in this case in comparison to other well-documented therapies.Conclusions:With on-going pulmonary bleeding, a single lumen ETT intubation offers advantages to the commonly advocated methods of treating a PAC-induced pulmonary artery rupture.

3:00 PM Abstract No. 191 Risk factors for chest port infections in patients with solid cancers: multivariate analysis of 1158 patients

To identify risk factors for chest port (port) infections in patients with solid cancers. A retrospective chart review of 1158 adult patients (≥ 18 years old) with solid cancers (male/female: 551/607, mean age: 58.1 years) who had a port placed between January 2012 and December 2015 was conducted to identify patients port infections. Port placement was generally avoided in patients with severe neutropenia (absolute neutrophil count or ANC<500/μL). The most frequent site of cancer was lung (n = 258, 22.3%) followed by breast (n = 240, 20.7%). Port infections included port site (local) and blood stream infections. The patients were divided into two groups based on the records of port infections (infection vs non-infection). Variables including the patients’ demographics, medical history, laboratory data at the time of port placement, medication used, and port characteristics were compared between groups. To elucidate risk factors for port infections, multivariate proportional subdistribution hazard regression analyses were performed. A total of 389,815 catheter-days (median per patient: 522 catheter-days) were observed. Port infections were identified in 80 patients (6.9%) including 45 with port-site, 27 with bloodstream, and 8 with both. The infection rate was 0.21/1000 catheter-days. The median time to infection was 244 days (Range, 11-828 days). The infection group had significantly more patients with history of prior port placement (p = .01) and use of double lumen port (P = .001), and significantly shorter median duration of follow-up (P = .001) compared to the non-infection group. In backward stepwise multivariate analyses, prior port placement (p = 0.03, HR = 2.23, 95% CI [1.08-4.62]), use of double-lumen port (p = 0.01, HR = 2.08, 95% CI [1.15-3.74]) thrombocytopenia (platelet count<150,000/μL) (p = 0.01, HR = 2.16, 95% CI [1.19-3.90]) remained statistically significant. Neutropenia (ANC<1500/μL) was not the risk factor. Solid cancer patients with thrombocytopenia or a history of prior port need to be closely monitored for port infections. A single lumen port would be advised in these subgroups.

Cannulation for veno-venous extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) is described as a modified, smaller cardiopulmonary bypass circuit. The veno-venous (VV) ECMO circuit drains venous blood, oxygenate the blood, and pump the blood back into the same venous compartment. Draining and reinfusing in the same compartment means there are a risk of recirculation. The draining position within the venous system, ECMO pump flow, return flow position within the venous system and the patients cardiac output (CO) all have an impact on recirculation. Using two single lumen cannulas or one dual lumen cannula, but also the design of the venous cannula, can have an impact on where within the venous system the cannula is draining blood and will affect the efficiency of the ECMO circuit. VV ECMO can be performed with different cannulation strategies. The use of two single lumen cannulas draining in inferior vena cava (IVC) and reinfusing in superior vena cava (SVC) or draining in SVC and reinfusing in IVC, or one dual lumen cannula inserted in right jugular vein is all possible cannulation strategies. Independent of cannulation strategy there will be a risk of recirculation. Efficiency can be reasonable in either strategy if the cannulas are carefully positioned and monitored during the dynamic procedure of pulmonary disease. The disadvantage draining from IVC only occurs when there is a need for converting from VV to veno-arterial (VA) ECMO, reinfusing in the femoral artery. Then draining from SVC is the most efficient strategy, draining low saturated venous blood, and also means low risk of dual circulation.