Pulsed Doppler ultrasonography guidance for catheterization of the subclavian vein: a randomized study

BACKGROUND: Catheterization of the subclavian vein may lead to severe complications. The current randomized study compared a technique of pulsed Doppler ultrasonography guidance and the standard method for subclavian vein catheterization. METHODS: Standard and Doppler ultrasonography guidance methods were performed by the same physician in 286 patients, 143 in each group. Primary end points were immediate complications (arterial puncture, pneumothorax, wrong position of catheter tip), failures, the number of subclavian vein catheterizations with immediate complication or failure, the number of skin punctures per catheterization, and the time to placement of the guide wire. The secondary end points were the determination of predicting factors of successful cannulation in each group. RESULTS: Both groups were similar according to morphologic parameters of the patients. A greater number of subclavian vein catheterizations were performed on the right side using Doppler guidance (105 vs. 73, P < 0.01). Doppler guidance decreased complications (5.6% vs. 16.8%, P < 0.01), largely because of a smaller number of catheters for which the tip was defined to be in incorrect position (0.7% vs. 7.7%, P < 0.01). The time to catheterization was longer with Doppler guidance (300 vs. 27 s, P < 0.001). Failures, catheterizations of the subclavian vein with immediate complications or failure, and the total number of skin punctures per catheterization were similar in both groups. Using Doppler guidance, the presence of a good Doppler signal (124 of 143) was predictive of successful catheterization (123 successful cannulations, P < 0.001). CONCLUSIONS: Doppler guidance reduces the incidence of inappropriately positioned subclavian catheters.     

Femoral vascular catheterization in critically ill infants and children

The success rate and complications from femoral arterial and venous catheterization in infants and children in a university affiliate pediatric intensive care unit were determined prospectively over a 2-year period. We also performed a meta-analysis from published literature to determine the combined estimates of noninfectious and infectious complications (with 95% confidence limits) using the inverse variance-weighted method. Success rates were 94.5% and 94.4% for femoral arterial (n=110) and venous (n=89) catheterizations, respectively, and were related to operator expertise, age, and hemodynamic status. Median age was 2.4 years and 1.1 year for arterial and venous catheterizations, respectively. Immediate complications were hematoma (10.9% arterial, 16.8% venous) and minor bleeding (13.6% arterial, 13.5% venous). Decreased pulses occurred with 7.7% of arterial catheterizations, and lower limb swelling occurred in 9.5% of venous catheterizations. Vascular complications occurred only in infants and resolved within 7-14 days. Catheter-related infections occurred in 1.9% of arterial and 3.6% of venous catheterizations. The mean duration of catheterization was 5.3 days and 6.3 days with femoral arterial and venous catheterizations, respectively. Meta-analysis of published studies shows that the estimates for noninfectious complications were 5.0%, 10.1%, 1.1%, and 1.8% for femoral arterial, femoral venous, axillary arterial, and nonfemoral venous catheters, respectively. The estimates for catheter-related infection were 2.5%, 3.7%, and 3.0% for femoral arterial, femoral venous, and nonfemoral venous catheters, respectively. The meta-analytic estimates for complication rates from published literature are not significantly different from the rates observed in our study. Femoral arterial and venous catheterization in infants and children are safe with an expected high success rate and acceptably low complication rates.     

Three-dimensional electron microscopy of the photosystem II core complex

Risk factors for central venous catheter (CVC)-related bacteraemia among infants admitted to a neonatal intensive care unit (NICU) were analysed and the impact of surveillance and continuing education on the incidence of this complication investigated. Among patients admitted to a NICU, CVC-related bacteraemia increased from 1/15 (7%) in 1987 to 11/26 (42%) in 1988 (P = 0.01). Coagulase-negative staphylococci isolated from bacteraemia patients showed clonal diversity by plasmid and chromosomal fingerprinting. A review of CVC care procedures suggested breaches in aseptic techniques. Catheter-care technique was revised to ensure maximal aseptic precautions, including the use of sterile gloves, gown and drapes. The new policy was promoted by a continuing education programme and regular feed-back of CVC-related bacteraemia incidence to NICU staff. In the four-year follow-up period, the attack-rate of CVC-related bacteraemia decreased to 18/156 (12%) patients [relative risk (RR): 0.27, 95% confidence interval (CI); 0.15-0.51; P < 0.001 vs the previous period]. By using the Cox's model proportional hazards, very low birthweight and the period before use of strict aseptic CVC care were found to be predictors of increased risk of catheter-related bacteraemia after adjustment for duration of catheterization. These data provide further evidence that strict aseptic precautions during the maintenance and utilization of CVC can contribute to lower the risk of catheter infection in critically ill neonates. Regular feedback of surveillance data was associated with a progressive decrease in incidence of infection, suggesting that it improved staff compliance with aseptic precautions.     

Central venous catheters. Prospective surveillance of a hospital

OBJECTIVES: All the central venous catheters (CVC) inserted at the Saint-Antoine Hospital between December 5, 1994 and June 6, 1995 were prospectively studied in order to better define practices in the management of CVC and to determine the rate of catheter-related infections. METHODS: The following data were recorded for each CVC: insertion procedure, clinical data, catheter dressings, removal, catheter-related infections, bacteriological findings. Catheter-related infections were distinguished from probably catheter-related infections and localized skin infections. RESULTS: Among 325 patients, a total of 414 catheters were inserted. At the end of the surveillance period, 350 (85%) had been removed, 43 (10%) were still in place and 21 (5%) were lost to follow-up. Analysis of procedures such as cutaneous disinfection, routine replacement of the i.v. sets or changes of dressings showed wide variations between care units and within the same unit. The overall incidence of catheter-related infections was 0.24 per 100 days of catheterization. Infections occurred 29 +/- 34 days after insertion. Microorganisms responsible for catheter-related bacteremia were mostly Gram positive (84%) and Gram negative (16%). Sixty-two infections (15%) were clinically suspected by physicians, leading to the catheter removal in 84% of cases. Out of the 43 CVC sent to the laboratory, 29 (67%) were negative (i.e., "sterile") in quantitative culture of the tips as described by Brun-Buisson, suggesting that the CVC was unnecessarily removed. Bacteriological analysis ordered by physicians were not always relevant. For example, 76% of CVC received by the laboratory were systematically sent although they were not suspected of infections. Conversely, only 61% of exsudate formation at the insertion site were collected and analyzed. CONCLUSION: This study was designed to recall good guidelines to the hospital staff. Results will lead to the development of a better use of antiseptics and to the implementation of appropriate and standardized procedures to reduce risk infection.     

Implantable catheter systems. Experiences with 1000 patients with central venous ports

OBJECTIVE: To assess retrospectively duration of functioning and rate of complications of a totally implantable venous access system used for long-term chemotherapy. PATIENTS AND METHODS: Between 1985 and 1993, a central venous access system (Port-a-Cath) had been implanted subcutaneously for long-term chemotherapy in 1000 patients (479 males, 521 females; mean age 49 [15-86] years). Follow-up observations lasted until the end of the chemotherapy or the removal of the system. RESULTS: Mean time of functioning of the catheter system was 284 (2-1563) days. The complication rate was 12.8%: catheter infection in 4.9% and catheter thrombosis in 3.2%. A further 4.7% of patients had less common complications (malfunction, catheter dislocation, skin necrosis, catheter break or disconnection, pneumothorax). A total of 119 (11.9%) systems had to be removed because of complications. The rates of infection and of other complications were significantly lower in patients with solid tumours (2 and 4%, respectively) than in those with haematological disease (6 and 8%) (P < 0.05 for each). CONCLUSION: Totally implantable venous access systems are suitable for long-term chemotherapy and cause few complications.     

Foundations'' impact on policy making: results from a pilot study

Thirty-two consecutive patients with haematological disorders, in need of a permanent central venous catheter (CVC) were randomly allocated to have their CVC bandages (Tegaderm) changed once (OAW, n = 20) or twice (TAW, n = 19) a week. The two randomization arms were balanced in respect of age, sex, and underlying disease. The exit site of the CVC was inspected daily through the transparent bandage and erythema was noted. If severe erythema occurred, daily wet gauze dressings were applied. Samples for bacterial cultures were taken from the exit site of the CVC at every change of bandages. There was no difference in complications leading to removal of the CVC between the two groups (7/20 OAW vs. 7/19 TAW) or in CVC survival-time (P = 0.4). However, the OAW group had more positive CVC tip cultures (OAW 11/14 vs. TAW 2/9; P < 0.05) and a tendency to: (i) more extra dressings (P = 0.08); (ii) more cultures from the exit skin site showing high numbers of colony forming units (P = 0.07); (iii) shorter time to first exit site infection (P = 0.09); and (iv) more Gram-positive septicaemias (P = 0.08). Both clinical and bacteriological data in this study indicate that changing transparent polyurethane CVC bandages twice a week is superior to once a week.     

Histopathology, clinical findings and treatment of renal hydatidosis

There is an increasing trend toward the use of indwelling central venous catheters (CVC) for maintenance hemodialysis. Although such devices are necessary in some problematic cases, the general use of CVC is worrisome. Not only may CVC prejudice the ultimate success of future permanent vascular access, but CVC also may be associated with reduced dialysis delivery and with several important complications. This review summarizes recent developments in catheter design, placement techniques, maintenance of the indwelling catheter, and complications of CVC use. Based on cumulated experience, a judicious position is taken that recognizes the place of CVC among the various access options but that favors permanent vascular access whenever feasible.     

Peptide vaccination with an anchor-replaced CTL epitope protects against human papillomavirus type 16-induced tumors expressing the wild-type epitope

PURPOSE: Upper-extremity thrombosis appears to be more frequent today, comprising about 2% of all deep venous limb thrombosis. Its severity depends on the type of possible complications, i.e., pulmonary embolism and post-thrombotic sequelae. In this retrospective series, we investigated both the predisposing factors and the evolution of upper-extremity deep venous thrombosis. METHODS: Forty-nine consecutive patients (24 men and 25 women, mean age 50.2 years) with upper extremity deep venous thrombosis documented by color Doppler ultrasonography (n = 47) or phlebography (n = 2) were included in the study. RESULTS: Clinical manifestations were mainly pain (81.6%) and edema (93.9%). Mean time between the onset of clinical signs and diagnosis was 7.2 days. Thrombosis involved humeral (26.5%), axillary (46.9%), subclavian (73.5%) and jugular (24.5%) veins. Causative factors were malignancies (32.7%), venous catheters (22.4%), deep venous thrombosis related to effort or thoracic outlet syndrome (22.5%) and thrombophilic states (8.2%). During the 6-month follow-up, six patients developed symptomatic pulmonary embolism (12.2%); one recurrence (2.2%) and 19 post-thrombotic sequelae such as residual edema (36.7%) were also observed. Initial therapy included heparin administration, principally subcutaneous low molecular weight heparins (n = 36/49). CONCLUSION: This series highlights the fact that upper-extremity deep venous thrombosis is mainly secondary to either malignancies or catheterization. Moreover, it confirms that color Doppler ultrasonography may be useful in the diagnosis of the disease and also underlines the high frequency of severe complications, i.e., pulmonary embolism and post-thrombotic sequelae. Finally, this study also demonstrates that low molecular weight heparins should be considered as the initial treatment of choice.     

A review of 560 Hickman catheter insertions

Indwelling, cuffed, tunnelled, central venous (Hickman) catheters are increasingly being used for venous access and the administration of chemotherapy for oncological patients. This paper reviews the technical problems associated with the percutaneous insertion of these catheters and the complications arising from their use. Five hundred and sixty catheters were inserted; 31.3% had complications at insertion, most commonly precipitation of an arrhythmia (13.9%). Arterial puncture occurred in 3.8% and pneumothorax in 1.6%. Catheters remained in place for a median period of 91 days. Forty percent of catheters were removed electively on completion of treatment; 30.2% required removal because of complications, which included sepsis, migration, thrombosis and blockage. Twenty percent of patients died with their catheter in place, 8.5% were still in situ and 1.6% were removed because of patient non compliance. Sepsis remains the commonest, long term complication, with staphylococcus epidermidis being the organism isolated most frequently. There were no catheter-related deaths.     

Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic experience

OBJECTIVES: The purpose of this study was to determine the safety and efficacy of rescue echocardiographically guided pericardiocentesis as a primary strategy for the management of acute cardiac perforation and tamponade complicating catheter-based procedures. BACKGROUND: In this era of interventional catheterization, acute tamponade from cardiac perforation as a complication is encountered more frequently. The safety and efficacy of echocardiographically guided pericardiocentesis in this life-threatening situation and outcomes of patients managed by this technique are unknown. METHODS: Of the 960 consecutive echocardiographically guided pericardiocenteses performed at the Mayo Clinic (1979 to 1997), 92 (9.6%) were undertaken in 88 patients with acute tamponade that developed in association with a diagnostic or interventional catheter-based procedure. Most of the patients were hemodynamically unstable at the time of pericardiocentesis, with clinically overt tamponade in 40% and frank hemodynamic collapse (systolic blood pressure <60 mm Hg) in 57%. Clinical end points of interest were the success and complication rates of rescue pericardiocentesis and patient outcomes, including the need for other interventions, clinical and echocardiographic follow-up findings and survival. RESULTS: Rescue pericardiocentesis was successful in relieving tamponade in 91 cases (99%) and was the only and definitive therapy in 82% of the cases. Major complications (3%) included pneumothorax (n=1), right ventricular laceration (n=1) and intercostal vessel injury with right ventricular laceration (n=1); all were treated successfully. Minor complications (2%) included a small pneumothorax and an instance of transient nonsustained ventricular tachycardia; all were resolved spontaneously. Further surgical intervention was performed in 16 patients (18%). No deaths resulted from the rescue pericardiocentesis procedure itself. Early death (<30 days) in this series was due to injuries from cardiac catheter-based procedures (n=3), perioperative complications (n=2) and underlying cardiac diseases (n=2). Clinical or echocardiographic follow-up for a minimum of 3 months or until death (if <3 months) for recurrent effusion or development of pericardial constriction was achieved in 87 (99%) of the patients. CONCLUSIONS: Echocardiographically guided pericardiocentesis was safe and effective for rescuing patients from tamponade and reversing hemodynamic instability complicating invasive cardiac catheter-based procedures. For most patients, this was the definitive and only therapy necessary.     

Pulsed Doppler sonography for the guidance of vein puncture: a prospective study

Blind deep venous puncture is an invasive procedure with risks of serious complications compromising the availability of veins for future punctures or endangering the patient's life. We designed a new hand-held pulsed Doppler probe for coaxial guidance of the puncture needle and a dedicated pulsed Doppler device displaying the depth of the measurement volume. We used this technique prospectively in two independent centers (the nephrology department and the intensive care unit) involving senior as well as junior staff members. Either the non-Doppler or the Doppler method were randomly selected for subclavian vein catheterization in 100 patients and for internal jugular vein catheterization in 30 patients. The success rate on the first attempt was 86.2% for the non-Doppler method versus 96.8% for the Doppler method (p = 0.03). The failure rate of the non-Doppler method used by junior staff members was 9.2%, reduced to 1.5% (p = 0.05) by secondary use of the Doppler method and/or help from a senior staff member (rescue procedure). Pulsed Doppler guidance reduced significantly the failure rate of venous punctures especially when used by seniors or by juniors after a training period.     

Pharmacokinetics and concentration-effect relationship after propofol infusion

This report summarizes data obtained via a mailed questionnaire from 129 Department of Veterans Affairs (VA) hospitals regarding current practices in the care of central venous catheters (CVCs) used for total parenteral nutrition (TPN). The size of VA hospitals' acute medical-surgical beds ranged from 14 to 1320 (median 168) beds. Over 6000 patients annually received CVCs for TPN. Hospitals reported using triple-lumen catheters most frequently as their CVC for TPN (80.3%). A povidone-iodine scrub was used to prepare the skin for CVC insertion by 72.6% of reporting hospitals. Sixty percent of hospitals used transparent polyurethane dressings. Care of CVCs varied among hospitals. Catheter-related infection and sepsis rates were within the national average, although < 50% of responding hospitals provided data on these outcomes. The results of this survey point to the need for a national standardized database relative to patients receiving TPN via a CVC.     

Management of central venous catheter occlusions and repairs

Central venous catheter (CVC) occlusions have the potential of compromising patient care because of the inability to administer needed medications, parenteral nutrition, and blood products. The practitioner responsible for the care of these catheters can be instrumental in the diagnosis and treatment of catheter-related occlusions by becoming familiar with typical complications and their causes. This article describes the causes and possible solutions for some of the most common types of mechanical, thrombus, and precipitate occlusions with the CVC. A discussion of CVC fracture will help the practitioner in the resolution of this complication.     

Percutaneous cardiac catheterization and atrial balloon septostomy in pediatrics

Between November, 1971, and July, 1975, 688 patients ranging in age from six hours to 21 years have undergone percutaneous transfemoral venous and/or arterial catheterization at the University of Oregon Health Sciences Center. This represents 93% of all venous catheterizations of the right side of the heart and 97% of all arterial catheterizations of the left side of the heart in the pediatric age range. One hundred and ninety-five patients (29% of the group) weighed 5 kg or less and 133 (20% of the group) were neonates. There were virtually no complications following the venous studies. The complication rate following percutaneous arterial studies is lower than is the reported experience with cut-down arteriotomies. Long-term survival following percutaneous atrial balloon septostomy in D-transposition of the great arteries was comparable to that following cut-down balloon septostomy. The ease of accomplishment, significantly lower complication rate, and successful accomplishment of atrial balloon septostomy prompt us to advocate that the percutaneous technique of cardiac catheterization be extended to include the neonate and young infant who weighsless than 5 kg.     

Long-term results of thoracoscopic resection of lung cysts

The treatment modality of spontaneous pneumothorax is extended by the introduction of an endoscopically applicable linear stapler. During the last 2 years 35 resections of cysts in 33 patients (24 men, 9 women, age median mean = 34 years) were started thoracoscopically in our hospital. Indications were: First pneumothorax (n = 15), recurrent pneumothorax (n = 16) and prophylactic resections (n = 4). A switch to open thoracotomy was necessary in 4 cases (11%) because of interpleural adhesions or large bullae. The median operation time was mean = 90 min. (range 60-240), the postoperative hospital stay mean = 8 days (range 4-25). Early complications occurred in 2 cases: One hematothorax, which was treated thoracoscopically, and one recurrent pneumothorax at the ninth postoperative day, which was treated by a chest drain. The follow up investigation 2 to 24 months (median mean = 6) after therapy was complete in 28 cases. It revealed that only 2 late recurrences (7%) occurred after 4 and 6 months. One was treated thoracoscopically again, the other one by thoracotomy. The endoscopically treated patients had less complaints than patients after thoracotomy. Only 4 patients complained of sensitivity in the scars due to weather changes. In conclusion the minimal-invasive resection of lung parenchyma represents an effective alternative to open thoracotomy with a much better quality of life, a low rate of complications and a comparable rate of recurrences.     

Everything you wanted to know about sex a perspective on the first symposium on Comparative Neuroendocrinology of Vertebrate Reproduction and Growth: Molecular, Cellular and Organismal Aspects

Over a one-year period, all coagulase-negative staphylococci (CoNS) from blood cultures, cerebrospinal fluids and peritoneal effluents from patients in a major Danish university hospital were investigated for susceptibility to penicillin G; methicillin; gentamicin; netilmicin; amikacin; erythromycin; clindamycin; fusidic acid; rifampicin; tetracycline; chloramphenicol; ciprofloxacin; teicoplanin; and vancomycin. Among the CoNS-isolates, 56% were resistant to methicillin, 51% to gentamicin, 28% to ciprofloxacin, and 5% to teicoplanin. Blood culture CoNS-isolates from patients with a central venous catheter (CVC) were more often resistant to various antibiotics compared to CoNS-isolates from patients without a CVC, e.g. methicillin (72% vs 21%), gentamicin (65% vs 22%) (p<0.00000001). Great diversity in antibiotic resistance between the wards was found; methicillin resistance (in most cases multiple antibiotic resistance) was in particular associated with consumption of broad-spectrum beta-lactams, quinolones, and total antibiotic consumption in a ward. Thus, the antibiotic policy of a ward is an important factor for antibiotic resistance among CoNS.     

Negative catheter-tip culture and diagnosis of catheter-related bacteremia

The accuracy of paired quantitative blood cultures (PQtBCs) collected in pediatric Isolator 1.5-ml tubes compared to central venous catheter (CVC) segment cultures (hub and tip) to diagnose catheter-related bacteremia (CRB) was evaluated in 58 bacteremic adult patients. The second aim of this study was to state precisely whether the tip or the hub (or both) of the infected device was the source of the bacteremia in case of significant results of PQtBC. Fifty-eight bacteremic patients with suspected CRB entered the study. In 52 patients, the diagnosis was obtained before CVC removal by PQtBC and was confirmed by CVC segment cultures: CRB in 30 patients, non-catheter-related bacteremia in 22 patients. Six patients had CRB not found by PQtBC. 1) PQtBC is 83% sensitive, 100% specific (negative predictive values 78%, positive predictive values 100%). 2) Sixteen bacteremic patients had authentic hub-related bacteremia (positive hub culture associated with negative tip cultures). When CRB is suspected in bacteremic patients, a negative tip culture cannot exclude the diagnosis of CRB. In all cases, CVC tip culture must be associated either with PQtBC or with hub cultures.     

Sneddon''s syndrome: apropos a case

The case of a 76 year old patient diagnosed of severe dysphagia by familiar oculopharyngeal muscular dystrophy is presented. Central venous catheterization (right internal jugular) was required for parenteral nutrition. A few minutes after catheterization, the patient developed respiratory arrest and coma and later cerebral vascular accident with left flaccid hemiplegia, with the ischemic lesion being focalized in the right parietooccipital region as well as in the left of the posterior fossa were observed. Aneurismatic dissection of the bilateral vertebral artery during lateralization of the head may be a cause of the lesions presented by the patient associated to arterial spasm or not. In central venous catheterization the possible complications derived from the position of the neck may carry must be taken into account.     

Bloodstream infection associated with needleless device use and the importance of infection-control practices in the home health care setting

The influence of infection-control practices on bloodstream infection (BSI) risk was examined in a home health care setting in which three needleless devices were used consecutively. A case-control study and a retrospective cohort study were conducted. Risk factors for BSI included lower education level, younger age, having a central venous catheter (CVC) with multiple ports, or having a tunneled CVC. Among patients with a tunneled CVC, those at greatest risk had been allowed to shower rather than bathe and to get their exit site wet (P<.01). A high proportion (49%) of isolates were hydrophilic gram-negative bacteria, suggesting water sources of infection. In the cohort study, the BSI rate decreased as the frequency of changing the needleless device end cap increased from once weekly up to every 2 days, suggesting that the mechanism for BSI may involve contamination from the end cap. These findings may help to develop infection-control measures specific to home health care.     

Meta-analysis of the efficacy of extradural clonidine to relieve postoperative pain: an impossible task

PURPOSE: The diagnostic accuracy and rate of complications of CT-guided core biopsies (CB) from suspected tumors of the chest were compared to the accuracy a complications of fine-needle aspiration biopsies (FNAB). METHODS: The accuracy in the diagnosis of a benign or malignant lesion of 79 FNAB (19.5 G self-aspirating cutting needle) and of 83 CB (18 G automated core biopsy) and the rates of pneumothorax, pleural drainage and hemoptysis were retrospectively evaluated. RESULTS: With FNAB, the sensitivity for malignant lesions was 62.1% and the accuracy 68.4%. With CB the sensitivity amounted to 85.9% and accuracy to 86.7%. The rate of pneumothorax was 25.3% following FNAB, with a drainage rate of 5.1% compared to 19.3% and 6.0%, respectively, following CB. The rate of pneumothorax and drainage increased with increasing path length through aerated lung. In advanced emphysema, the pneumothorax rate did not increase; however, in pneumothoraces, pleural drainage was mandatory in 20% of FNAB and in 100% of CB. Hemoptysis without any therapeutic consequences occurred in 3.8% following FNAB and in 6.0% following CB. CONCLUSIONS: With CB diagnostic accuracy can be clearly increased without an obvious increase in the complication rate. However, in patients with obvious emphysema, the pleural drainage rate of pneumothorax may be higher following CB.