Is a neutral head position safer than 45-degree neck rotation during ultrasound-guided internal jugular vein cannulation? Results of a randomized controlled clinical trial.

Anesth Analg. 2012 Apr;114(4):777-84

Authors: Lamperti M, Subert M, Cortellazzi P, Vailati D, Borrelli P, Montomoli C, D'Onofrio G, Caldiroli D

Abstract
BACKGROUND: The optimal degree of neck rotation during internal jugular vein (IJV) cannulation remains undetermined because previous studies suggested using sonography, but without puncturing the vein. We assessed whether a neutral position (NP) of the head (0 degrees) during ultrasound-guided cannulation of the IJV was safer than rotating the neck to 45 degrees head turned. The effect of these 2 positions during ultrasound-guided cannulation on major complications was the primary outcome. Overall complications, venous access time, and perception of difficulty during the procedure were also evaluated.
METHODS: A prospective, randomized, controlled, nonblinded study was conducted in a tertiary neurosurgical hospital. Patients undergoing major elective neurosurgical procedures requiring a central venous line were randomly allocated to 2 groups; ultrasound-guided cannulation of the IJV was then performed using an out-of-plane orientation.
RESULTS: One thousand four hundred twenty-four patients were evaluated, but 92 were excluded; 670 were allocated to the head turned group and 662 to the NP group. Cannulation was 100% successful. Demographic data were similar in the 2 groups except for IJV positions. There were only 10 major complications: 6 in the 0-degree NP group and 4 in the 45-degree head turned group. The frequency of these complications was not different between the 2 groups. The overall complication rate was 13%, and was higher in women, in patients with ASA physical status ?II, and in patients with a smaller diameter vein, or when the vein was located deeper and lateral or in the anterolateral position. An increased venous access time was associated with an increased rate of overall complications. The perception of difficulty performing the procedure with the head placed in the 2 positions was not statistically different in either group.
CONCLUSION: A head NP was as safe as a 45-degree neck rotation during ultrasound-guided IJV cannulation with regard to both major and minor complications, and venous access time was similar. Ultrasound guidance helps determine optimal head rotation for IJV cannulation.

PMID: 22253269 [PubMed - indexed for MEDLINE]

Is alcohol-based hand disinfection equivalent to surgical scrub before placing a central venous catheter?

Anesth Analg. 2012 Mar;114(3):622-5

Authors: Burch TM, Stanger B, Mizuguchi KA, Zurakowski D, Reid SD

Abstract
BACKGROUND: Waterless antiseptic surgical hand scrub (1% chlorhexidine gluconate and 61% ethyl alcohol, Avagard™; 3M Health Care, St. Paul, MN), alcohol-only cleanser (62% ethyl alcohol), and traditional surgical scrub (5-minute scrub with 4% chlorhexidine soap using a sterile scrub brush with water) are techniques used for hand cleansing and disinfection. We hypothesized that alcohol-only cleanser and waterless antiseptic scrub (Avagard) would be as effective as a traditional surgical scrub for hand cleansing before placement of central venous catheters.
METHODS: Fingers of subjects were plate-cultured for 24 hours after 5 methods of hand cleansing: method 1: traditional surgical scrub (n = 49 plates produced by 14 subjects); method 2: traditional surgical scrub (5-minute scrub with water, brush, and 4% chlorhexidine soap) followed by a 15-minute break, then alcohol-only cleanser (62% alcohol) (n = 49 plates produced by 14 subjects); method 3: alcohol-only cleanser alone (n = 49 plates produced by 14 subjects); method 4: alcohol-only cleanser (62% alcohol), followed by a 15-minute break, then traditional surgical scrub (5-minute scrub with brush, and 4% chlorhexidine soap with water) (n = 49 plates produced by 14 subjects); and method 5: waterless surgical scrub (Avagard) alone (n = 116 plates produced by 38 subjects). The 15-minute break was introduced to allow a short period of recontamination, and to test for residual effects from prior cleansing.
RESULTS: Alcohol-only cleanser alone (method 3) was significantly less effective than the traditional surgical scrub (method 1) (P < 0.001; 82% plate growth). Waterless surgical scrub (Avagard) (method 5) had a 0% observed difference (95% confidence interval [CI]: -14% to 11%) compared with the traditional 5-minute scrub (method 1) (P = 0.99; 16% plate growth). When a traditional surgical scrub was used first followed by a 15-minute period of recontamination, there was a 6% observed difference in method 2 from reference (method 1) (95% CI: -10% to 22%), and 0% observed difference in method 4 from reference (95% CI: -15% to 15%).
CONCLUSION: As the initial cleansing method, the alcohol-only cleanser (method 3) was significantly less effective than the traditional surgical scrub (method 1) (P < 0.001).

PMID: 22190557 [PubMed - indexed for MEDLINE]

Micropuncture needles combined with ultrasound guidance for unusual central venous cannulation: desperate times call for desperate measures--a new trick for old anesthesiologists.

Anesth Analg. 2012 Mar;114(3):634-7

Authors: Castillo D, McEwen DS, Young L, Kirkpatrick J

Abstract
Central vascular access can be a very challenging task in patients with skeletal deformities such as ankylosing spondylitis, kyphosis, and chin-on-chest deformity. The use of traditional methods of accessing the central venous circulation in these patients can require multiple attempts and may lead to significant complications such as bleeding, pneumothorax, and vascular injury. Ultrasound-guided central venous access has become a very common procedure in the United States and Europe; its efficacy and safety have been demonstrated, and together with the use of micropuncture needles, the technique can facilitate central venous access in complicated cases.

PMID: 22190551 [PubMed - indexed for MEDLINE]

An estimation of right- and left-sided central venous catheter insertion depth using measurement of surface landmarks along the course of central veins.

Anesth Analg. 2011 Jun;112(6):1371-4

Authors: Kim MC, Kim KS, Choi YK, Kim DS, Kwon MI, Sung JK, Moon JY, Kang JM

In this study we sought to determine whether the topographical measurement along the course of the central veins can estimate the approximate insertion depths of central venous catheters (CVC).

PMID: 21233490 [PubMed - indexed for MEDLINE]

Central venous catheter-induced cardiac tamponade: a preventable complication.

Anesth Analg. 2011 Jun;112(6):1280-2

Authors: Shamir MY, Bruce LJ

PMID: 21613198 [PubMed - indexed for MEDLINE]

Real-time three-dimensional ultrasound-guided central venous catheter placement.

Anesth Analg. 2011 Feb;112(2):378-81

Authors: Dowling M, Jlala HA, Hardman JG, Bedforth NM

We present the first description of real-time 3-dimensional ultrasound for insertion of a central venous catheter in a surgical patient. An HD11 XE™ ultrasound machine with a V8-4 transducer (Philips Medical Systems, Bothell, WA) was used throughout. Three-dimensional multiplanar and volume-rendered views allowed us to simultaneously view the neck anatomy in 3 orthogonal planes. Needle entry into the vein and subsequent catheter placement were also visualized. We were able to rotate the views in real time, thereby enabling visualization of the catheter within the lumen of the vein. The ability to see simultaneous real-time short- and long-axis views along with volume perspective without altering transducer position is an exciting development with the potential to confer a safety benefit to the patient. Although the operator is required to assimilate more information, the limitations we encountered were mainly related to processing power and transducer size, which we expect will be overcome with advancing technology.

PMID: 21156975 [PubMed - indexed for MEDLINE]

Metformin-induced lactic acidosis: no one left behind.

Crit Care. 2011 Jan 21;15(1):107

Authors: Vecchio S, Protti A

ABSTRACT: Metformin is a safe drug when correctly used in properly selected patients. In real life, however, associated lactic acidosis has been repeatedly, although rarely, reported. The term metformin-induced lactic acidosis refers to cases that cannot be explained by any major risk factor other than drug accumulation, usually due to renal failure. Treatment consists of vital function support and drug removal, mainly achieved by renal replacement therapy. Despite dramatic clinical presentation, the prognosis of metformin-induced lactic acidosis is usually surprisingly good.

PMID: 21349142 [PubMed - as supplied by publisher]

Cerebrospinal fluid lactate: Is it a reliable and valid marker to distinguish between acute bacterial meningitis and aseptic meningitis?

Crit Care. 2011 Jan 14;15(1):104

Authors: Prasad K, Sahu JK

ABSTRACT: Cerebrospinal fluid (CSF) lactate assay has been a subject of research since 1925. A systematic review by Huy and colleagues in the previous issue of Critical Care summarizes data from 25 studies evaluating the role of CSF lactate in the differential diagnosis between acute bacterial and aseptic meningitis. The authors concluded that CSF lactate is a good single indicator and a better marker compared with conventional markers. But concerns remain because of poor quality of included studies, lack of proper 'gold standard', and limited applicability. More studies with a rigorous design are needed to determine definitively whether CSF lactate assay is a reliable and valid marker to distinguish between acute bacterial meningitis and aseptic meningitis.

PMID: 21349143 [PubMed - as supplied by publisher]

Survey study of anesthesiologists' and surgeons' ordering of unnecessary preoperative laboratory tests.

Anesth Analg. 2011 Jan;112(1):207-12

Authors: Katz RI, Dexter F, Rosenfeld K, Wolfe L, Redmond V, Agarwal D, Salik I, Goldsteen K, Goodman M, Glass PS

Nearly 20 years ago it was shown that patients are exposed to unnecessary preoperative testing that is both costly and has associated morbidity. To determine whether such unnecessary testing persists, we performed internal and external surveys to quantify the incidence of unnecessary preoperative testing and to identify strategies for reduction.

PMID: 21081771 [PubMed - indexed for MEDLINE]

Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery.

Anesth Analg. 2010 Dec;111(6):1378-87

Authors: Joshi GP, Chung F, Vann MA, Ahmad S, Gan TJ, Goulson DT, Merrill DG, Twersky R,

Optimal evidence-based perioperative blood glucose control in patients undergoing ambulatory surgical procedures remains controversial. Therefore, the Society for Ambulatory Anesthesia has developed a consensus statement on perioperative glycemic management in patients undergoing ambulatory surgery. A systematic review of the literature was conducted according the protocol recommended by the Cochrane Collaboration. The consensus panel used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for providing suggestions. It was revealed that there is insufficient evidence to provide strong recommendations for the posed clinical questions. In the absence of high-quality evidence, recommendations were based on general principles of blood glucose control in diabetics, drug pharmacology, and data from inpatient surgical population, as well as clinical experience and judgment. In addition, areas of further research were also identified.

PMID: 20889933 [PubMed - indexed for MEDLINE]

Implantation of 3951 long-term central venous catheters: performances, risk analysis, and patient comfort after ultrasound-guidance introduction.

Anesth Analg. 2010 Nov;111(5):1194-201

Authors: Peris A, Zagli G, Bonizzoli M, Cianchi G, Ciapetti M, Spina R, Anichini V, Lapi F, Batacchi S

BACKGROUND: Despite evidence demonstrating improved safety with ultrasound-guided placement of central venous catheters (CVC) in comparison with the use of anatomical landmarks, ultrasound guidance is still not routinely used by all physicians when obtaining central venous access. METHODS: We report data pertaining to the placement of long-term CVCs in a 7-year period before and after ultrasound guidance was introduced. We included 3951 procedures (total of 1,642,402 catheter days) in our study: 1584 using the anatomical landmark method (landmark group, January 2000 to May 2003), and 2367 with ultrasound guidance (ultrasound group, June 2003 to May 2007). All procedures were performed by the same team of intensivists. Comparison criteria included procedural data, complications, patient's comfort, and perceptions. Variables were analyzed with Student's t test and ?(2) test. Multivariate analysis was performed according to the Cox proportional hazards regression model. RESULTS: Using ultrasound guidance, we noted a significant reduction in procedure time in both port (mean difference 4.9 ± 0.4 minutes, confidence interval [CI] 4.1 to 5.7) and tunneled catheter (mean difference 2.4 ± 0.8 minutes, CI 0.9 to 3.8) placement. The landmark method was associated with an increased risk of overall perioperative complications (4.5, CI 3.6 to 5.6). Among disease entities, acute leukemia patients had a significantly higher risk of CVC-related infections (2.6, CI 2.1 to 3.8). On the basis of questionnaires submitted to patients from both groups, ultrasound guidance was associated with improved patient comfort and satisfaction. CONCLUSIONS: Ultrasound guidance reduces complications and improves patient comfort. Further studies are needed to define whether acute leukemia patients should be considered a separate category with regard to the higher incidence of infections.

PMID: 20829559 [PubMed - indexed for MEDLINE]

Introduction of a rapid response system at a United States veterans affairs hospital reduced cardiac arrests.

Anesth Analg. 2010 Sep;111(3):679-86

Authors: Lighthall GK, Parast LM, Rapoport L, Wagner TH

BACKGROUND: We sought to determine the impact of a rapid response system on cardiac arrest rates and mortality in a United States veteran population. METHODS: We describe a prospective analysis of cardiac arrests in 9 months before and 27 months after institution of a rapid response system, and retrospective analysis of mortality 3.5 years before the intervention and 27 months after the intervention. The study included all inpatients from a university-affiliated United States Veterans Affairs Medical Center, before and after implementation of a rapid response system, including an educational program, patient calling criteria, and a physician-led medical emergency team. Primary end points were hospital-wide cardiac arrests and mortality rates normalized to hospital discharges. Comparisons of event rates between various time points during the implementation process were made by analysis of variance. RESULTS: Three hundred seventy-eight calls were made to the medical emergency team in the time period studied. Compared with preintervention time points, cardiac arrests were reduced by 57%, amounting to a reduction of 5.6 cardiac arrests per 1000 hospital discharges (P < 0.01). Mortality was reduced during the intervention, but this was attributable to a natural decrease occurring over all phases of the study. CONCLUSIONS: A significant reduction in the rate of cardiac arrests was realized with this intervention, as well as a trend toward lower mortality. We estimate that 51 arrests were prevented in the timeframe studied. Our results suggest that further reductions in morbidity can be realized by expansion of rapid response systems throughout the Veterans Affairs network.

PMID: 20624835 [PubMed - indexed for MEDLINE]

The impact of Trendelenburg position and positive end-expiratory pressure on the internal jugular cross-sectional area.

Anesth Analg. 2010 Aug;111(2):432-6

Authors: Marcus HE, Bonkat E, Dagtekin O, Schier R, Petzke F, Wippermann J, Böttiger BW, Teschendorf P

BACKGROUND: Increasing the cross-sectional area (CSA) of the right internal jugular vein facilitates cannulation and decreases complications. Maneuvers such as the Trendelenburg tilt position and ventilation with a positive end-expiratory pressure (PEEP) may increase the CSA of the right internal jugular vein. We determined the changes in the CSA in response to different maneuvers. METHODS: The CSA (cm(2)) of the right internal jugular vein was assessed in 50 anesthetized adult cardiothoracic surgery patients using 2-dimensional ultrasound. First, the CSA was measured in response to supine position with no PEEP (control condition, S0) and compared with 5 different randomly ordered maneuvers: (1) PEEP ventilation with 5 cm H(2)O (S5), (2) PEEP with 10 cm H(2)O (S10), (3) a 20 degrees Trendelenburg tilt position with a PEEP of 0 cm H(2)O (T0), (4) a 20 degrees Trendelenburg tilt position combined with a PEEP of 5 cm H(2)O (T5), and (5) a 20 degrees Trendelenburg tilt position combined with a PEEP of 10 cm H(2)O (T10). RESULTS: All maneuvers increased the CSA of the right internal jugular vein with respect to the control condition S0 (all P < 0.05). S5 increased the CSA on average by 15.9%, S10 by 22.3%, T0 by 39.4%, T5 by 38.7%, and T10 by 49.7%. CONCLUSION: In a comparison of the effectiveness of applying different PEEP levels and/or the Trendelenburg tilt position on the CSA of the right internal jugular vein, the Trendelenburg tilt position was most effective.

PMID: 20484538 [PubMed - indexed for MEDLINE]

Perioperative management of the adult with cystic fibrosis.

Anesth Analg. 2009 Dec;109(6):1949-61

Authors: Huffmyer JL, Littlewood KE, Nemergut EC

Since cystic fibrosis (CF) was first differentiated from celiac disease in 1938, the medical care of patients with CF has substantially improved. These improvements have resulted in a significant increase in median survival and the quality of life experienced by patients. The resultant increase in survival has caused the "average" CF patient to be a young adult and not a child. The gene that causes CF was first identified in 1989 and is the first gene discovered by positional cloning. Unfortunately, gene therapy for CF has not been successful, although it continues to hold great promise for future patient care. Although pulmonary disease is responsible for more than 90% of the morbidity and mortality in patients with CF, they also experience pancreatic disease, including diabetes mellitus, bone disease, hepatobiliary disease, and genitourinary disease. The optimal perioperative management of patients with CF requires an understanding of the relevant pathophysiology and the unique challenges presented by these patients. We reviewed these concepts, including special considerations such as liver and lung transplantation and pregnancy.

PMID: 19923526 [PubMed - indexed for MEDLINE]

Noninfectious serious hazards of transfusion.

Anesth Analg. 2009 Mar;108(3):759-69

Authors: Hendrickson JE, Hillyer CD

As infectious complications from blood transfusion have decreased because of improved donor questionnaires and sophisticated infectious disease blood screening, noninfectious serious hazards of transfusion (NISHOTs) have emerged as the most common complications of transfusion. The category of NISHOTs is very broad, including everything from well-described and categorized transfusion reactions (hemolytic, febrile, septic, and allergic/urticarial/anaphylactic) to lesser known complications. These include mistransfusion, transfusion-related acute lung injury, transfusion-associated circulatory overload, posttransfusion purpura, transfusion-associated graft versus host disease, microchimerism, transfusion-related immunomodulation, alloimmunization, metabolic derangements, coagulopathic complications of massive transfusion, complications from red cell storage lesions, complications from over or undertransfusion, and iron overload. In recent years, NISHOTs have attracted more attention than ever before, both in the lay press and in the scientific community. As the list of potential complications from blood transfusion grows, investigators have focused on the morbidity and mortality of liberal versus restrictive red blood cell transfusion, as well as the potential dangers of transfusing "older" versus "younger" blood. In this article, we review NISHOTs, focusing on the most recent concerns and literature.

PMID: 19224780 [PubMed - indexed for MEDLINE]