Cannula Tip Research Articles

Cryoneurotomy to Reduce Spasticity and Improve Range of Motion in Spastic Flexed Elbow: A Visual Vignette.

The flexed-elbow pattern of spasticity causes pain and reduced function and greater caregiver burden.1 Genet et al.1 reported the brachialis as the dominant muscle limiting extension. The musculocutaneous nerve (MSCN)–innervated brachialis and biceps brachii as well as the radial nerve–innervated brachioradialis are all implicated.1 Refractory spasticity after rehabilitation and chemodenervation with botulinum toxin type A may require selective surgical or neurolytic interventions to improve outcomes. The diagnostic anesthetic nerve block (DNB) has been used to assist in the evaluation of a muscle’s contribution to spasticity.1 The DNB can differentiate between spasticity and contracture and predict the outcome of surgical neurotomy. It was proposed in 2019 that cryoneurotomy is a safe percutaneous treatment for refractory spasticity.2 Long used in the anesthetic literature, cryoneurotomy is a mini-invasive technique that introduces a hand-held cryoprobe to a peripheral nerve and using the expansion of gas at the cannula tip to create an ice ball, which disrupts the nerve structure, causing axonotmesis. The distal fibers undergo Wallerian degeneration while the basal lamina and endoneurium are preserved, providing a scaffold for regeneration. A hallmark of the procedure is the lack of neuritis or neuroma formation.3 This retrospective chart review identified 11 adult patients with a flexed-elbow spasticity who had previously undergone a screening DNB then a subsequent cryoneurotomy from February 1, 2018, to February 28, 2020, in one clinic (Table 1). All patients had spasticity of at least grade 2 on the Modified Ashworth Scale (MAS), improvement in elbow range of motion, and/or reduction in spasticity after DNB to the MSCN ± radial nerve. All had previously been treated with botulinum toxin type A for their flexed-elbow spasticity with nine of our patients with ongoing botulinum toxin type A at a relatively high average dose of 444 U, with 231 U in the upper extremity. Images were hosted on a secure cloud server. This study was approved by the local institutional ethics board, with patient consent to participate. TABLE 1 - Patient demographics (N = 11) Age at first DNB, mean (SD), yr 53 (15) Sex, female/male, n 4/7 Etiology of spasticity, n Spinal cord injury 2 Stroke (hemorrhagic/ischemic) 7 (4/3) Multiple sclerosis 1 Traumatic brain injury 1 Affected side, right/left, n 4 / 7 Disease onset to first DNB, mean (SD), yr 9 (5) Our video presentation provides an illustration of the interventional techniques, the reduction in spasticity, and increased range of motion over a mean follow-up of 12.5 mos. Each patient was screened with a DNB to the brachialis branch of the MSCN and three patients with additional radial nerve blocks to the brachioradialis. The MSCN and radial nerves were localized with ultrasound guidance. A small bore, Teflon-coated hypodermic needle was inserted. Needle placement was confirmed with ultrasound guidance and electrical stimulation at less than 1 mA causing brachialis or brachioradialis contraction. One millilitre of 2% lidocaine was injected around the target nerve. A positive response was determined by a reduction in MAS, an improvement in passive ± active range of motion, no adverse outcomes, and no loss of function, on DNB. All patients in this study had positive DNB results and went on to cryoneurotomy of the MSCN with three additional to the radial nerve branch to the brachioradialis with the technique described by Winston et al.2 Documenting outcomes in spasticity remain a challenge for research. Our vignette illustrates the changed range of motion and spasticity.

Evaluation of nerve capture using classical landmarks for genicular nerve radiofrequency ablation: 3D cadaveric study

Background and objectivesRadiofrequency (RF) denervation of the superolateral genicular nerve (SLGN), superomedial genicular nerve (SMGN) and inferomedial genicular nerve (IMGN) is commonly used to manage chronic knee joint pain. However,...

Retroauricular thyroidectomy with a single-arm robotic surgical system: Preclinical cadaveric study.

In this study, we evaluate a new flexible, single-arm robotic system in performing thyroidectomy via a retroauricular approach. Four fresh cadavers were used. Technical details of the new system are discussed, and the comprehensive surgical procedures are described step by step. This single-port flexible system could be used to successfully perform retroauricular thyroidectomy. The ideal angle to dock the patient-side cart was at a 90° angle to the operating table. When the cannula tip was placed 10 to 15 cm away from the skin incision, positioning and full movement of all four instruments without collisions were possible. Three flexible instruments and an endoscope made the robotic dissection more efficient. We describe the first preclinical evaluation of an innovative, flexible, single-arm robotic surgical system for retroauricular thyroidectomy.

Electrolyte handling in the isolated perfused rat kidney: demonstration of vasopressin V2-receptor-dependent calcium reabsorption

Background The most profound effect of vasopressin on the kidney is to increase water reabsorption through V2-receptor (V2R) stimulation, but there are also data suggesting effects on calcium transport. To address this issue, we have established an isolated perfused kidney model with accurate pressure control, to directly study the effects of V2R stimulation on kidney function, isolated from systemic effects. Methods The role of V2R in renal calcium handling was studied in isolated rat kidneys using a new pressure control system that uses a calibration curve to compensate for the internal pressure drop up to the tip of the perfusion cannula. Results Kidneys subjected to V2R stimulation using desmopressin (DDAVP) displayed stable osmolality and calcium reabsorption throughout the experiment, whereas kidneys not administered DDAVP exhibited a simultaneous fall in urine osmolality and calcium reabsorption. Epithelial sodium channel (ENaC) inhibition using amiloride resulted in a marked increase in potassium reabsorption along with decreased sodium reabsorption. Conclusions A stable isolated perfused kidney model with computer-controlled pressure regulation was developed, which retained key physiological functions. The preparation responds to pharmacological inhibition of ENaC channels and activation of V2R. Using the model, the dynamic effects of V2R stimulation on calcium handling and urine osmolality could be visualised. The study thereby provides evidence for a stimulatory role of V2R in renal calcium reabsorption.

Simple Bimanual Technique of Internal Limiting Membrane Retrieval.

To describe a novel technique of internal limiting membrane retrieval. A 25-gauge vitrectomy was performed in all patients. After internal limiting membrane (ILM) peeling (after brilliant blue dye staining), the ILM was held with the forceps in the midvitreous cavity and a 25-gauge cannula mounted on a 2 mL of balanced salt solution-filled syringe was introduced. When the tip of the cannula made contact with the ILM, mild suction was applied, and the ILM was retrieved in the syringe. Internal limiting membrane retrieval was successful in the all the patients attempted. To conclude, bimanual technique of membranous tissue removal using a soft tip cannula under direct visualization is a safe and efficient technique that makes membrane retrieval a predictable process.

False Sense of Safety: Blunt Cannulas Cause the Majority of Severe Vascular Complications in Hyaluronic Acid Injection.

Vascular embolism is perhaps the most severe complication of hyaluronic acid injection.1 To avoid such catastrophic events, blunt cannulas were introduced.2 Theoretically, cannulas are considered safer than needles, as cannula tips are blunt rather than beveled and therefore less likely to penetrate vascular walls. However, as a matter of fact, the majority cases of severe hyaluronic acid–related intravascular events referred to our department were performed with cannulas instead of needles. Over the past 3 years, 28 severe cases of hyaluronic acid embolism were referred to our department (nine cases of unilateral blindness, one case of unilateral blindness with cerebral infraction, and 18 cases of a large area of soft-tissue necrosis). According to patient histories, 25 of 28 patients (89.3 percent) were injected with cannulas (range, 27 to 22 gauge) instead of needles. This finding suggests that the safety of use of cannulas in hyaluronic acid injections may have been overestimated. According to previous studies, thinner cannulas, especially those smaller than 25 gauge, can still punch through vascular walls when enough force is applied.3 Also, some cannula tips are sharper than others with the same gauge because of different designs by varying manufacturers (Fig. 1). Other than their underestimated penetration capability, aspiration can be more difficult with cannulas than with needles. Cannulas used in hyaluronic acid injections are often 40 to 50 mm in length, as sharp needles are usually ½ inch (12.7 mm) in length. This indicates that once hyaluronic acid enters the cannula, higher negative pressure and longer aspiration time would be required for the hyaluronic acid to retreat to the cannula base than in needles. The smoothness of the internal lining of the cannula also impacts the chance of successful aspiration. From the authors’ own experience, and that of many of our colleagues, poorly made cannulas have a rougher internal lining that can prevent successful aspiration, giving the injector the false impression of safety. The viscidity and the particle size of the hyaluronic acid product can affect the aspiration as well.4,5 Products with higher viscidity and larger particle size require a larger bore cannula/needle and a longer aspiration time to achieve successful aspiration. Other than the above factors, the method of aspiration that is used by many injectors nowadays is also questionable. Some injectors do not allow enough time for aspiration when the cannula/filler product requires longer to retreat to the syringe. When injecting with a liner or performing a fanning injection technique with cannulas, many injectors never aspirate or do so only when the cannula reaches the endpoint of the injection path. If a blood vessel is penetrated along the passage, the hyaluronic acid could enter the blood vessel during the retrograde injection at the point of penetration, causing an embolism.Fig. 1.: Varying quality and details of blunt cannulas by different manufacturers. Five cannulas of three sizes (27, 25, and 23 gauge) are shown. Cannulas A and C are made by the same manufacturer, and cannulas B, D, and E are made by another manufacturer. Despite having the same size (cannulas A and B, 27 gauge; and cannulas C and D, 25 gauge), the roundness of the tip shape of the distal openings and the smoothness of their outer coating are different.To avoid hyaluronic acid embolisms, the authors propose the following: (1) injectors should have a solid understanding of anatomy; (2) inject gently and avoid using cannulas smaller than 25 gauge, especially when injecting into high-risk areas such as the periorbital and glabella regions; (3) when using retrograde/fanning injection technique, aspirate and maintain negative pressure on entry all the way to the designated site; (4) use the cannula cautiously in deep layer injections; and (5) inject slowly and closely observe the injection site and the patient. Stop immediately if an embolism is suspected. With these precautions applied, the authors believe that we can lower the possibility of embolism when injecting with cannulas to the minimum. ACKNOWLEDGMENT This research was supported by the National Natural Science Foundation of China (no. 81971848). DISCLOSURE None of the authors has a financial interest in any of the products or devices mentioned in this article.

Numerical analysis of the effect of the design of axial-flow pump cannula tip on stagnation and recirculation zones in the left ventricle

Objective: to analyze the inflow cannula of an implantable axial-flow blood pump for a long-term left ventricular assist system in order to minimize thromboembolic complications. Materials and methods. Hemodynamics was considered for 4 different designs of the inflow cannula, from 0 mm to 25 mm long. Areas at the base of the cannula received the most attention. Analysis was performed using the OpenFOAM software. Results. It was revealed that sizes of stagnation and recirculation zones directly depended on the length of the cannula when placed in the left ventricle. Accordingly, longer cannula increases the risk of thrombosis. Conclusion. The design of an inflow cannula determines the likelihood of thrombosis in the cannula. Longer inflow cannula increases stagnation and recirculation zones. This provides a basis for a search for other possible modifications.

Three-dimensional nonlinear finite element model to estimate backflow during flow-controlled infusions into the brain.

Convection-enhanced delivery is a technique to bypass the blood-brain barrier and deliver therapeutic drugs into the brain tissue. However, animal investigations and preliminary clinical trials have reported reduced efficacy to transport the infused drug in specific zones, attributed mainly to backflow, in which an annular gap is formed outside the catheter and the fluid preferentially flows toward the surface of the brain rather than through the tissue in front of the cannula tip. In this study, a three-dimensional human brain finite element model of backflow was developed to study the influence of anatomical structures during flow-controlled infusions. Predictions of backflow length were compared under the influence of ventricular pressure and the distance between the cannula and the ventricles. Simulations with zero relative ventricle pressure displayed similar backflow length predictions for larger cannula-ventricle distances. In addition, infusions near the ventricles revealed smaller backflow length and the liquid was observed to escape to the longitudinal fissure and ventricular cavities. Simulations with larger cannula-ventricle distances and nonzero relative ventricular pressure showed an increase of fluid flow through the tissue and away from the ventricles. These results reveal the importance of considering both the subject-specific anatomical details and the nonlinear effects in models focused on analyzing current and potential treatment options associated with convection-enhanced delivery optimization for future clinical trials.

Real-time intraoperative ultrasound biomicroscopy for determining graft orientation during Descemet's membrane endothelial keratoplasty.

To evaluate the intraoperative use of ultrasound biomicroscopy (UBM) during Descemet's membrane endothelial keratoplasty (DMEK) to determine graft's orientation. Prospective interventional study of eight eyes of seven patients who underwent DMEK. Following the identification of correct graft orientation using 'Blue cannula tip' sign during DMEK surgery, UBM was used to ascertain graft's orientation. The rate of successful DMEK graft orientation determined by the UBM was registered and verified postoperatively by anterior segment-optical coherence tomography (OCT). Intra- and postoperative complications, postoperative clearance of the cornea, corrected distance visual acuity and endothelial cell loss were also noted. The study included five males and two females aged 54-82years with corneal oedema due to Pseudophakic bullous keratopathy (n=5), Fuchs' endothelial dystrophy (n=2). In all cases, the technique allowed proper determination of the graft's orientation. In one case, 'blue cannula tip' sign showed correct orientation while UBM identified an upside-down graft. The graft was inverted in the anterior chamber using fluid jets, and repeat 'blue cannula tip' sign and UBM examination both showed correct orientation. In all cases, postoperative anterior segment-OCT demonstrated correct graft orientation. Use of intraoperative UBM to determine graft orientation during DMEK correlated with proper graft orientation, as was verified postoperatively by anterior segment-OCT. The use of UBM can be particularly helpful in cases of poor graft visibility due to opaque corneal stroma, pigment or blood in the anterior chamber during surgery, or when the blue tint of the graft fades rapidly, which may preclude proper determination of graft's orientation.

Clinical evaluation of a new dispersive aortic cannula

Cerebral injury is a serious complication in open-heart surgery. Once it occurs, it causes significant disability and death. We developed a novel dispersive aortic cannula named the Stealth Flow cannula and used it as a standard aortic cannula in cardiopulmonary bypass. The aim of this study was to evaluate the efficiency of this aortic cannula. A total of 182 consecutive patients undergoing cardiac surgery using cardiopulmonary bypass were studied. The patients were divided into two groups: the Soft-Flow cannula group (n = 89) and the Stealth Flow cannula group (n = 93). Patients with a shaggy aortic arch were excluded from this study because the cannulae were inserted at the ascending aorta with a cannula tip directed toward the aortic root in these cases. Patients with multiple arterial perfusion sites were also excluded. Complications including early mortality, perioperative stroke, and intraoperative aortic injury were compared between the two groups. Age, operative procedure, cardiopulmonary bypass time, and the Japan SCORE were not significantly different between the groups. In comparisons between the Stealth Flow and Soft-Flow groups, the incidences of early mortality, perioperative stroke, intraoperative aortic dissection, and all complications were 1.08% versus 1.12% (p = 0.98), 1.1% versus 2.2% (p = 0.53), 0% versus 1.1% (p = 0.33), and 1.1% versus 3.4% (p = 0.29), respectively. The incidence of major cardiovascular events, including early death, perioperative stroke, and aortic dissection, was not different. The Stealth Flow cannula, which was designed based on our previous experimental study, contributed to reducing cerebral and aortic events as much as the Soft-Flow cannula in the present clinical study.

Extracorporeal Life Support Organization (ELSO): Guidelines for Neonatal Respiratory Failure.

Extracorporeal Life Support Organization (ELSO): Guidelines for Neonatal Respiratory Failure.

Bulb Cannula Safety for Breast Fat Grafting.

Autologous fat transfer is a common technique to refine the contour of the breast after prosthetic augmentation or reconstruction, correcting remaining asymmetries by injecting previously harvested fat tissue with a cannula. Current procedures are often performed without visualization of the cannula at the delivery site and may require subsequent verification of the implant’s integrity. The present paper aims to evaluate the safety of a new bulb tip cannula to be used during breast implant procedures for injecting fat adjacent to a breast implant that reduce the risk of damaging the implant. Two conventional cannulae and 3 bulb cannulae, which have an atraumatic distal tip, were tested in a simulated implant-puncture setting in 3 positions (at 0°, 45°, and 90° of incidence). A Tensile Tester (Instron, High Wycombe, UK) was used to apply force with each cannula device and record the amount of force applied in the attempt to penetrate the implants used, with shell layers having a variable thickness. No implant rupture was observed with the bulb tip cannulae regardless of size or the position in which the cannulae were pressed against the implants. The cannula opening was not impeded and tended to bend instead; 27% of the cases with the conventional lipo-cannulae caused an implant rupture. The bulb tip cannula could enhance the safety of the fat transfer procedure by ensuring no iatrogenic implant disruption and optimal delivery of the fat tissue.

Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019 in Shanghai, China.

Severe cases of coronavirus disease 2019 (COVID-19) cannot be adequately managed with mechanical ventilation alone. The role and outcome of extracorporeal membrane oxygenation (ECMO) in the management of COVID-19 is currently unclear. Eight COVID-19 patients have received ECMO support in Shanghai with seven with venovenous (VV) ECMO support and one veno arterial (VA) ECMO during cardiopulmonary resuscitation. As of March 25, 2020, four patients died (50% mortality), three patients (37.5%) were successfully weaned off ECMO after 22, 40, and 47 days support, respectively, but remain on mechanical ventilation. One patient is still on VV ECMO with mechanical ventilation. The partial pressure of oxygen/fractional of inspired oxygen ratio before ECMO initiation was between 54 and 76, and all were well below 100. The duration of mechanical ventilation before ECMO ranged from 4 to 21 days. Except the one emergent VA ECMO during cardiopulmonary resuscitation, other patients were on ECMO support for between 18 and 47 days. In conclusion, ensuring effective, timely, and safe ECMO support in COVID-19 is key to improving clinical outcomes. Extracorporeal membrane oxygenation support might be an integral part of the critical care provided for COVID-19 patients in centers with advanced ECMO expertise.

18 Stop the Burn: A Smoking and Home Oxygen Safety Initiative with Use of Firebreaks

Abstract Introduction COPD is a chronic pulmonary disease treated with home oxygen. The single most common cause of COPD is cigarette smoking. Approximately 1.4 million people in the US use long-term oxygen therapy for treatment of hypoxic COPD. Smoking is an addictive risky behavior and smoking on oxygen therapy is responsible for the majority of home oxygen fires and deaths. Up to 52% of patients who use oxygen therapy continue to smoke in spite of these risks. At least 1,000 burn injuries per year occur when oxygen cannula tips ignite after coming in close contact with cigarettes, lighters, or matches. Flames travel externally and internally along the tubing toward the oxygen concentrator, which can explode. Previous prevention efforts have focused on counseling and education of patients and their caregivers; however, the habit continues, causing burn injury admissions and increasing health care costs. Methods Our ABA verified burn center admitted 90 burn injuries during July 2015 to September 2019 related to smoking on oxygen. Given the mechanism of injury, further preventive efforts were researched, and firebreak devices were identified as a secondary preventive measure to attempt to reduce negative consequences of smoking on oxygen. A firebreak device is fitted in the oxygen tubing near the patient and also near the oxygen concentrator. The firebreak acts as a thermal fuse by stopping the oxygen supply when triggered, preventing the flames from burning to the oxygen concentrator. Our program goal was to develop a safety initiative using educational information and firebreak devices. Information was shared at the regional Trauma committee and with local EMS, Fire and on Facebook. The program was initiated in 2018. We worked with local EMS and Fire agencies to install the firebreak devices in nursing homes, assisted living facilities and in patients’ homes who use oxygen. Results Our program distributed 225 firebreak kits, which included no smoking signs, a home oxygen safety checklist, an educational video link, nasal cannula tubing and 2 firebreak devices. Since the initiation of the program, the number of burn injury admissions from smoking on oxygen decreased from an average of 24/year to an average of 9/year. Conclusions Standardizing the use of firebreak kits in the community for those smoking on oxygen or using oxygen stops a fire by halting the oxygen supply thereby potentially decreasing burn admissions. Therefore, we recommend the consideration of firebreak kits for patients who continue to smoke while using oxygen to Stop the Burn. Applicability of Research to Practice Future research is recommended to determine the effectiveness of firebreak kits as a safety measure for all individuals who use oxygen.

Feasibility study on continuous spinal analgesia in all stages of labor.

Feasibility study on continuous spinal analgesia in all stages of labor.

Verification of the Deep Brain Stimulation Electrode Position Using Intraoperative Electromagnetic Localization

Background: Electromagnetic (EM) localization has typically been used to direct shunt catheters into the ventricle. The objective of this study was to determine if this method of EM tracking could be used in a deep brain stimulation (DBS) electrode cannula to accurately predict the eventual location of the electrode contacts. Methods: The Medtronic AxiEM^TM system was used to generate the cannula tip location directed to the planned target site. Prior to clinical testing, a series of phantom modelling observations were made. Results: Phantom trials (n = 23) demonstrated that the cannula tip could be accurately located at the target site with an error of between 0.331 ± 0.144 and 0.6 ± 0.245 mm, depending on the orientation of the delivery system to the axis of the phantom head. Intraoperative EM localization of the DBS cannula was performed in 84 trajectories in 48 patients. The average difference between the planned target and the EM stylet location at the cannula tip was 1.036 ± 0.543 mm. The average error between the planned target coordinates and the actual target electrode location (by CT) was 1.431 ± 0.607 and 1.145 ± 0.636 mm for the EM stylet location in the cannula (p = 0.00312), indicating that EM localization reflected the position of the target electrode more accurately than the planned target. Conclusions: EM localization can be used to verify the position of DBS electrodes intraoperatively with a high accuracy.

Pneumothorax as a Complication of Liposuction.

BackgroundPneumothorax is a rare complication of liposuction resulting from injury to the lung parenchyma.ObjectivesThis study aimed to determine the incidence of pneumothorax complicating liposuction, describe an archetypal presentation, identify risk factors, and propose options for risk reduction.MethodsIn a retrospective chart review, liposuction procedures performed over a 16-year period by 8 surgeons in 1 practice were screened for pneumothorax. Cases featuring pneumothorax were analyzed to ascertain risk factors, presentation, and pathogenesis.ResultsAmong the 16,215 liposuction procedures performed during the study period, 7 pneumothoraxes were identified (0.0432%). Six (85.7%) were female. Three (42.9%) had previous liposuction. Six cases (85.7%) included liposuction of the axillary region. All cases featured depression of intra/postoperative oxygen saturations as the initial sign. Three (42.9%) were identified intraoperatively. All patients were transferred to a hospital for imaging. Five (71.4%) underwent chest tube placement. Two (28.6%) were treated with observation alone. Pneumothoraxes were left-sided in 4 cases (57.1%), and right-sided in 3 cases (42.9%). In early cases, 1.5-mm infiltration cannulas were used; in 2016 cannula size was changed to 3-4 mm for infiltration and 4-5 mm for liposuction.ConclusionsPossible risk factors for pneumothorax include liposuction of the axilla, use of flexible infiltration cannulas, and scarring from previous liposuction. We recommend including pneumothorax as a potential complication during informed consent, performing infiltration with a stiff >3.5-mm cannula, minimizing positive-pressure ventilation, emphasized awareness of cannula tip location in all patients but particularly in patients with previous liposuction or scar tissue, and increased caution when operating in the axillary area.Level of Evidence: 4

Small damage of brain parenchyma reliably triggers spreading depolarization

ABSTRACTObjectives: Spreading depolarization (SD) is a well-recognized component of the stress response of the cortex to its acute injury. Cortical SD has been shown to occur in severe brain insults and standard neurosurgical procedures in patients and is supposed to promote delayed secondary brain injuries. Stereotactic surgery and site-specific intracerebral microinjections produce a small tissue injury when a thin needle is inserted directly into the brain parenchyma (via the cannula guide). The present study was designed to examine whether such a parenchymal damage can trigger SD.Methods: Experiments were performed in awake freely moving rats with simultaneous video-monitoring of behavior and recording of SD-related DC potentials in the cortex and striatum. A parenchymal damage was produced by 1-mm protruding of thin (0.3-mm diameter) cannula beyond the tip of cannula guide preliminary implanted into the amygdala or deep cortical layers.Results: We found that the micro-injury of the brain parenchyma the volume of which did not exceed 0.3 mm3 was sufficient to initiate SD in a very high proportion of rats (75-100%). The amygdala showed increased resistance against the injury-induced SD compared to the cortex. We further showed that SD triggered by the local micro-injury invaded remote intact regions of the cortico-striatal system and evoked specific changes in spontaneous animal behavior.Discussion: The findings indicate that SD may represent a previously unidentified side effect of local parenchymal injury during site-specific microinjections and stereotactic surgery.

Extracorporeal Membrane Oxygenation Cannula Malposition

Malposition of the extracorporeal membrane oxygenation (ECMO) cannulas is not frequently reported in central cannulation technique: we aimed to present an ECMO cannula malposition in follow-up in a neonate case. The patient was followed up three days on ECMO support with optimum hemodynamics. On the third day swelling occurred in the left face area within hours. Chest radiography showed that the arterial cannula tip was identified upwardly facing, which implied malposition of the cannula in the left carotid artery. After repositioning the cannula, swelling on the left side of the face completely disappeared in 4 hours. Clinicians should be alert for ECMO cannula malposition. Chest radiography which can be accessed quickly and easily can be beneficial for the diagnosis.

Sustained Total All-Region (STAR) Perfusion for Norwood Reconstruction

The acute phase of recovery following the Norwood procedure can be complicated by considerable instability due in part to bleeding, acute kidney injury, systemic inflammatory response, and low cardiac function. The traditional conduct of cardiopulmonary bypass with cooling, re-warming, myocardial ischemia, and upper or lower body ischemia likely exacerbates these problems. Total body perfusion during Norwood reconstruction, without significant cooling or ischemic time to any organs, may improve postoperative recovery by reducing coagulopathy and end-organ injury. Here, we introduce a novel technique for sustained total all-region perfusion of the heart, upper body, and lower body throughout the Norwood operation.