Skin Puncture Site Research Articles

Positioning internal jugular venous catheters using the right third intercostal space in children.

Central venous catheters are used for pressure measurement, and drug and fluid therapy in children. Several reports have described serious complications related to catheter positioning. We evaluated the possibility of using the right third intercostal space as an anatomic landmark for determining the optimal insertion depth of a central venous catheter from the right internal jugular vein. The distance between the skin puncture site and the right third intercostal space (SK-ICS) was measured in 83 children. The catheter was inserted to a depth equal to the measured distance. Postoperatively, the distance between the catheter tip and the radiographic junction of the superior vena cava and the right atrium was measured. This was defined as the optimal catheter length, which placed the catheter tip at the SVC/RA junction (SK-SVC/RA). A significant correlation was found between the SK-ICS and SK-SVC/RA (regression equation: SK-SVC/RA = 0.35 + 0.98 x SK-ICS, r2 = 0.8554). Based on the data obtained, a simple formula, SK-ICS-1 (cm), predicted that a CVC would be positioned above the RA in 98.8% of patients. Using the right third intercostal space as an anatomic landmark allows positioning of the catheter tip in the SVC near to but not in the RA in children.

Somatic paravertebral nerve blockade Incidence of failed block and complications

The failure rate and complications following thoracic and lumbar paravertebral blocks performed in 620 adults and 42 children were recorded. The technique failure rate in adults was 6.1%. No failures occurred in children. The complications recorded were: inadvertent vascular puncture (6.8%); hypotension (4.0%); haematoma (2.4%); pain at site of skin puncture (1.3%); signs of epidural or intrathecal spread (1.0%); pleural puncture (0.8%); pneumothorax (0.5%). No complications were noted in the children. The use of a bilateral paravertebral technique was found approximately to double the likelihood of inadvertent vascular puncture (9% vs. 5%) and to cause an eight‐fold increase in pleural puncture and pneumothorax (3% vs. 0.4%), when compared with unilateral blocks. The incidence of other complications was similar between bilateral and unilateral blocks.

Platelet activation results in a redistribution of glycoprotein IV (CD36).

To investigate the possibility that thrombin and/or other platelet activators change the platelet surface expression of glycoprotein IV (GPIV, CD36), we used a panel of five GPIV-specific monoclonal antibodies (OKM5, 5F1, FA6-152, 8A6, and F13) directed against different epitopes. All these antibodies bound to resting platelets in a concentration-dependent and saturable manner, as determined by flow cytometry of washed platelets. Thrombin (1 U/mL) induced an approximately twofold increase in the platelet surface binding of each of these monoclonal antibodies. Immunofluorescence microscopy demonstrated an internal pool of GPIV that, after thrombin stimulation, redistributed to the platelet surface. In a whole-blood flow-cytometric assay, alpha-thrombin and the thromboxane A2 analogue U46619 each resulted in an approximately twofold increase in the platelet surface binding of OKM5, whereas ADP had a more modest effect, and collagen and epinephrine had little effect. The activation-induced up-regulation of the platelet OKM5 epitope occurred in vivo as demonstrated by flow cytometric analysis of whole blood emerging from a standardized skin puncture site. In summary, both in vitro and in vivo platelet activation results in increased platelet surface expression of GPIV, as a result of a redistribution of GPIV from an internal pool.

Contamination of subclavian vein catheters: An intraluminal culture method

An intraluminal culture method was evaluated for central venous catheters and compared to conventional catheter tip cultures and cultures from the insertion site. The colonization-rate of the catheters was 43·7% using conventional tip culture, 34·4% with the intraluminal method and 40·1% at the skin puncture site. Only 37·5% of the catheters showed identical bacteria at the skin puncture site and catheter-tip, compared with 87·5% between intraluminal culture and catheter-tip culture ( P < 0·05).

Acetylcholinesterase

Summary An oedematous pre-eclamptic patient received lumbar epidural analgesia during labour. Clear fluid leaked from the skin puncture site for 4 days. The fluid was analysed using protein electrophoresis for cholinesterase enzymes and was found not to contain the cerebrospinal fluid specific form of the enzyme, acetylcholinesterase. The sensitivity of this test was explored using serial dilutions of cerebrospinal fluid. It is now possible to say that the leaking fluid did not contain cerebrospinal fluid.

Recommendation for collection of skin puncture blood from children, with special reference to production of reference values.

Reliable reference values need to be collected under standardized conditions. In order to enable comparison of values observed on patients with reference values, it is also desirable to use the same standardized conditions on patients. The present recommendation was produced as a joint effort of representatives of the clinical chemists and paediatricians of Scandinavia and describes the following details. Preparation of the child before specimen collection (food intake, time of day, physical activity, posture, environment), preparation of skin puncture site (warming, disinfection, ointment), instruments for blood collection (lancet, blood collection vessel), site of puncture (plantar surface of foot, finger, ear lobe), collection of emerging blood and handling and storage of the specimen.

A comparative study of ‘Op-site’ and ‘Nobecutan gauze’ dressings for central venous line care

A comparative study of ‘Op-site’ and ‘Nobecutan-gauze’ dressings for central venous lines was performed. Seventy-seven long antebrachial and 68 infraclavicular subclavian catheters were studied. A statistically significant reduction in the incidence of positive cultures from the catheter tip and from the skin puncture site was found with the ‘Nobecutan-gauze’ dressing. No difference in the incidence of catheter-related septicaemia was found. The theoretical advantage of being able to observe signs of inflammation when ‘Op-site’ was used did not reduce the incidence of local infection at the skin puncture site. In conclusion we found that a ‘Nobecutan-gauze’ dressing was a satisfactory alternative to an ‘Op-site’ dressing.

Weber-Christian disease with nephrotic syndrome.

Percutaneous renal biopsy in a child with nephrotic syndrome was followed by copious oozing of a clear, oily liquid from the skin puncture site. Subsequently, inflamed subcutaneous nodules appeared over the trunk and extremities suggesting Weber-Christian panniculitis. Extensive liquefication of fat occurred, especially over the abdomen, hips, and scrotum. Attacks of panniculitis subsided in nine months. The child received an eight-week therapy with cyclophosphamide and prednisone, and has remained free of proteinuria for one year.

Infection from intravenous catheters.

<h2>Abstract</h2> A study of 118 patients who were treated using intravenous polyethylene catheters is reported. 45% of the catheter tips were infected and 4 patients had bacteræmia from the same organism as that cultured from the catheter and skin. The incidence of infection was not related to the length of time the catheter had been in situ, the make of catheter used, or the fluid given. It is suggested that great care should be taken to ensure that the skinpuncture site is sterile and remains clean and that the catheter should be removed as soon as possible.

Cancer Seeding From Needle Biopsy

To the Editor:— I have noticed two articles reporting liver biopsy tract seeding, and the rarity of this occurrence. 1,2 We have also had a case of a 54-year old man with carcinoma of the left portion of the colon. Needle biopsy of liver was performed April 3, 1967. A troublesome hemorrhagic papilloma began growing at the skin puncture site. The pathology report on this excised mass (Nov 17) was metastatic carcinoma. Apparently, seeding after liver biopsy is not so rare.