Symptomatic Upper Extremity Deep Venous Thrombosis After Laser Lead Extraction

ABSTRACT Introduction: Laser lead extraction is a well-established method for removing unwanted leads with low morbidity and mortality. In this small series of cases, we documented our experience with venous thrombosis after laser lead extraction. Methods: Retrospective data of patients who underwent laser lead extraction with postoperative axillo-subclavian vein thrombosis between May 2010 and January 2020 were analyzed. Demographic, operative, clinical, and follow-up characteristics of those patients were collected from our medical database. Results: Six patients underwent percutaneous laser lead extraction. Mean age of the patients was 64±7 years. And four of them were male. A total of 11 leads with a mean age of 92±43.8 months were extracted. Patients presented with painful arm swelling postoperatively. Conclusion: Laser lead extraction may lead to symptomatic upper extremity deep venous occlusion.

Acesso venoso subclávio via fossa supraclavicular guiado por ultrassonografia: é opção segura? / Subclavian venous access via supraclavicular foss guided by ultrasonography: is it a safe option?

Introdução: A canulação venosa central é técnica cuja execução ainda está associada com complicações mecânicas, trombóticas e infecciosas e a guiada por ultrassonografia parece reduzir a incidência dessas complicações, custos e tempo necessário para realizar o procedimento. No entanto raras evidências apoiam a utilização ultrassonografia para a canulação da veia subclávia via supraclavicular. Objetivos: Avaliar se o acesso venoso subclávio via fossa supraclavicular guiado por ultrassonografia em tempo real é seguro como alternativa para obtenção de acessos venosos profundos. Método: Estudo epidemiológico de intervenção, transversal, caracterizado como ensaio clínico, em pacientes de UTI. As variáveis foram: idade, gênero, peso, lateralidade puncionada, número de tentativas de canulação, tempo entre a obtenção da imagem e acesso da veia, profundidade da veia subclávia em relação à pele e complicações durante a colocação e permanência do cateter. Resultados: Realizou-se acessos em 18 pacientes A maioria das punções foram obtidas na primeira ou segunda tentativa compondo 72,2% dos procedimentos, com tempo médio para a execução de 9 min. Observou-se predomínio de profundidades entre 0,63 a 1,09 cm com média de 1 cm. A taxa de sucesso foi de 94,4% com 5,6% de complicações correspondente à uma punção arterial. Não houve nenhuma outra complicação mecânica, trombótica ou infecciosa. Conclusões: O procedimento é seguro, executado em 9 min e, em sua maioria, na primeira ou segunda tentativa com 5,6% de complicações, e profundidade a partir da pele de 1 cm

Introduction: Central venous cannulation is a technique whose execution is still associated with mechanical, thrombotic and infectious complications and ultrasound-guided cannulation seems to reduce the incidence of these complications, costs and time required to perform the procedure. However, rare evidence supports the use of ultrasonography for cannulation of the subclavian vein via the supraclavicular route. Objectives: To assess whether subclavian venous access via the supraclavicular fossa guided by real-time ultrasound is a safe alternative for obtaining deep venous access. Method: Interventional, cross-sectional epidemiological study, characterized as a clinical trial, in ICU patients. The variables were: age, gender, weight, punctured laterality, number of cannulation attempts, time between obtaining the image and accessing the vein, depth of the subclavian vein in relation to the skin, and complications during placement and permanence of the catheter. Results: Accesses were performed in 18 patients. Most punctures were obtained in the first or second attempt, comprising 72.2% of the procedures, with an average time for execution of 9 min. There was a predominance of depths between 0.63 and 1.09 cm with an average of 1 cm. The success rate was 94.4% with 5.6% of complications corresponding to an arterial puncture. There were no other mechanical, thrombotic or infectious complications. Conclusions: The procedure is safe, performed in 9 min and, mostly, in the first or second attempt with 5.6% of complications, and depth from the skin of 1 cm.KEYWORDS: Central venous catheterization. Ultrasound. Subclavian vein.DOI: /10.55684/80.2.26Visão ultrassonográfica verificando-se o fio-guia no lúmen da veia subclávia(LAT=lateral; MED=medial, VSC=veia subclávia; VBC=veia braquicefálica)Mensagem CentralA canulação venosa central é técnica cuja execução ainda está associada com complicações mecânicas, trombóticas e infecciosas, e a guiada por ultrassonografia parece reduzir a incidência dessas complicações, custos e tempo necessário para realizar o procedimentoPerspectivaA obtenção do acesso venoso central subclávio via fossa supraclavicular guiado por ultrassonografia aponta-se como técnica segura executada com tempo médio de 9 min, em sua maioria na primeira ou segunda tentativa, com incidência de complicações menores de 5,6%, e para sua canulação, observou-se profundidade média a partir da pele de 1 cm. O procedimento é seguro e boa alternativa para acesso venoso subclávio.

Evaluación morfológica del músculo subclavio en una muestra de material de autopsia: inferencias clínicas / Morphological evaluation of the subclavian muscle in a sample of autopsy material: clinical inferences

RESUMEN: El músculo subclavio (MS) guarda estrecha relación con las estructuras neurovasculares (ENV) en el tercio medio de la región clavicular, situación de suma importancia para la realización de procedimientos invasivos de esta región. Pocos estudios han determinado la distancia desde el MS hacia la vena subclavia (VS), arteria subclavia (AS) y plexo braquial (PB). El propósito de este estudio fue valuar la expresión morfológica del MS y su relación con las ENV en una muestra de especímenes cadavéricos frescos. Estudio descriptivo en el que se realizó disección anatómica sobre la región clavicular de 30 especímenes de cadáveres humanos frescos no reclamados del Instituto Nacional de Medicina Legal y Ciencias Forenses, Colombia. Se realizó la caracterización cualitativa y cuantitativa del MS y se determinó la relación del MS con las ENV en la región clavicular. El MS presentó una longitud de 102,4±10,3 mm, con un espesor anteroposterior de 8,8±1,9 mm y superoinferior de 7,0±1,9 mm. El MS se caracterizó así: tipo I en 12 (40 %) especímenes, tipo II en 18 especímenes, tipo IIa: 10 especímenes. No encontramos tipos III y IV. La VS, AS y PB se relacionaron con el MS en el tercio medial y medio de su longitud a una distancia desde el margen superior del MSde 9,4±2,2 mm, 11,3±2,1 mm y 12,0±1,5 mm respectivamente. Los MS se relacionaron con las ENV de la región clavicular en una zona comprendida entre el 36,2±3,6 % y 89,4±4,8 % de su longitud total. Los hallazgos cualitativos y morfométricos de este estudio enriquecen los conceptos anatómicos subclaviculares y son de utilidad para el manejo quirúrgico de fracturas de clavícula.

SUMMARY: The subclavian muscle (MS) is closely related to the neurovascular structures (VNS) in the middle third of the clavicular region, and is critical when performing invasive procedures in this region. Few studies have determined the distance from the MS to the subclavian vein (VS), subclavian artery (AS) and brachial plexus (PB). The purpose of this study was to evaluate the morphological expression of MS and its relationship with VNS in a sample of fresh cadaveric specimens. The study involved the anatomical dissection in the clavicular region of 30 specimens of fresh unclaimed human cadavers from the National Institute of Forensic Medicine and Sciences, Colombia. The qualitative and quantitative characterization of the MS was carried out and the relationship of the MS with the VNS in the clavicular region was determined. The MS presented a length of 102.4 ± 10.3 mm, with an anteroposterior thickness of 8.8 ± 1.9 mm and a superoinferior thickness of 7.0 ± 1.9 mm. The DM was characterized as follows: type I in 12 (40 %) specimens, type II in 18 specimens, type IIa: 10 specimens. We did not find types III and IV. The SV, AS and PB were related to the MS in the medial and middle third of its length at a distance from the upper edge of the MS of 9.4 ± 2.2 mm, 11.3 ± 2.1 mm and 12.0 ± 1,5 mm respectively. The MS were related to the VNS of the clavicular region in an area between 36.2 ± 3.6 % and 89.4 ± 4.8 % of its total length. The qualitative and morphometric findings of this study enrich the subclavicular anatomical concepts and are useful for the surgical management of clavicle fractures.

Damage control surgery for thoracic outlet vascular injuries: the new resuscitative median sternotomy plus REBOA / Cirugía de control de daños para lesiones del opérculo torácico: nuevo abordaje mediante esternotomía mediana y REBOA

Abstract Thoracic vascular trauma is associated with high mortality and is the second most common cause of death in patients with trauma following head injuries. Less than 25% of patients with a thoracic vascular injury arrive alive to the hospital and more than 50% die within the first 24 hours. Thoracic trauma with the involvement of the great vessels is a surgical challenge due to the complex and restricted anatomy of these structures and its association with adjacent organ damage. This article aims to delineate the experience obtained in the surgical management of thoracic vascular injuries via the creation of a practical algorithm that includes basic principles of damage control surgery. We have been able to show that the early application of a resuscitative median sternotomy together with a zone 1 resuscitative endovascular balloon occlusion of the aorta (REBOA) in hemodynamically unstable patients with thoracic outlet vascular injuries improves survival by providing rapid stabilization of central aortic pressure and serving as a bridge to hemorrhage control. Damage control surgery principles should also be implemented when indicated, followed by definitive repair once the correction of the lethal diamond has been achieved. To this end, we have developed a six-step management algorithm that illustrates the surgical care of patients with thoracic outlet vascular injuries according to the American Association of the Surgery of Trauma (AAST) classification.

Resumen El trauma vascular torácico está asociado con una alta mortalidad y es la segunda causa más común de muerte en pacientes con trauma después del trauma craneoencefálico. Se estima que menos del 25% de los pacientes con una lesión vascular torácica alcanzan a llegar con vida para recibir atención hospitalaria y más del 50% fallecen en las primeras 24 horas. El trauma torácico penetrante con compromiso de los grandes vasos es un problema quirúrgico dado a su severidad y la asociación con lesiones a órganos adyacentes. El objetivo de este artículo es presentar la experiencia en el manejo quirúrgico de las lesiones del opérculo torácico con la creación de un algoritmo de manejo quirúrgico en seis pasos prácticos de seguir basados en la clasificación de la AAST. que incluye los principios básicos del control de daños. La esternotomía mediana de resucitación junto con la colocación de un balón de resucitación de oclusión aortica (Resuscitative Endovascular Balloon Occlusion of the Aorta - REBOA) en zona 1 permiten un control primario de la hemorragia y mejoran la sobrevida de los pacientes con trauma del opérculo torácico e inestabilidad hemodinámica.

Tratamento de oclusão arterial em membro superior causada por costela cervical / Treatment of upper limb arterial occlusion caused by a cervical rib

Resumo A síndrome da costela cervical ocorre quando o triângulo intercostoescalênico é ocupado por uma costela cervical, deslocando o plexo braquial e a artéria subclávia anteriormente, o que pode gerar dor e espasmo muscular. O objetivo deste estudo é discutir sobre o diagnóstico da síndrome da costela cervical e as possibilidades de tratamento. Este desafio terapêutico descreve a condução clínica e cirúrgica de uma paciente de 37 anos com obstrução arterial em membro superior causada por costela cervical.

Abstract The cervical rib syndrome occurs when the interscalene triangle is occupied by a cervical rib, displacing the brachial plexus and the subclavian artery forward, which can cause pain and muscle spasms. The objective of this study is to discuss diagnosis of the cervical rib syndrome and treatment possibilities. This therapeutic challenge describes clinical and surgical management of a 37-year-old female patient with upper limb arterial occlusion caused by a cervical rib.

Investigation and control of outbreaks of Candida Pelliculosa catheter-related bloodstream infection in the neurosurgical intensive care unit / 中国基层医药

Objective:To investigate the causes of the outbreak of Candida Pelliculosa catheter-related bloodstream infection in the neurosurgical intensive care unit (ICU), find out the source of infection and the route of transmission, and provide evidence for the prevention and control of nosocomial infection. Methods:An epidemiological investigation and environmental hygiene monitoring were made in patients with Candida Pelliculosa catheter-related bloodstream infection who received treatment in March and April 2019 in Houma People's Hospital, China. Comprehensive measures were taken to control the outbreaks of Candida Pelliculosa catheter-related bloodstream infection. Results:There were four patients with Candida Pelliculosa catheter-related bloodstream infection in the ICU of Neurosurgery Department of Houma People's Hospital, China. Eight samples were collected from these four patients. Ten strains were isolated and identified positive for Candida Pelliculosa. Drug sensitivity test revealed identical results: the minimum inhibitory concentration (MIC) of 5-fluorocytosine, amphotericin B, fluconazole, itraconazole and voriconazole was ≤ 4 mg/L, ≤ 0.5 mg/L, < 1 mg/L, ≤ 0.12 mg/L and ≤ 0.06 mg/L, respectively. No target bacteria were detected from the environment. Candida Pelliculosa infection was not observed after taking comprehensive control measures such as strengthening hand hygiene supervision in medical staff and thorough disinfection of the environment. Conclusion:Poor hand hygiene compliance in medical staff in neurosurgical ICU and non-sufficient environmental disinfection may be the main causes for the outbreak of Candida Pelliculosa catheter-related bloodstream infection.

The new surface landmarks for blind axillary vein puncture

Abstract Objective: To compare the efficacy of blind axillary vein puncture utilizing the new surface landmarks for the subclavian method. Methods: This prospective and randomized study was performed at two cardiology medical centers in East China. Five hundred thirty-eight patients indicated to undergo left-sided pacemaker or implantable cardioverter defibrillator implantation were enrolled, 272 patients under the axillary access and 266 patients under the subclavian approach. A new superficial landmark was used for the axillary venous approach, whereas conventional landmarks were used for the subclavian venous approach. We measured lead placement time and X-ray time from vein puncture until all leads were placed in superior vena cava. Meanwhile, the rate of success of lead placement and the type and incidence of complications were compared between the two groups. Results: There were no significant differences between the two groups in baseline characteristics or number of leads implanted. There were high success rates for both strategies (98.6% [494/501] vs. 98.4% [479/487], P=0.752) and similar complication rates (14% [38/272] vs. 15% [40/266], P=0.702). Six cases in the control group developed subclavian venous crush syndrome and five had pneumothorax, while neither pneumothorax nor subclavian venous crush syndrome was observed in the experimental group. Conclusion: We have developed a new blind approach to cannulate the axillary vein, which is as effective as the subclavian access, safer than that, and also allows to get this vein without the guidance of fluoroscopy, contrast, or echography.

Anatomical Landmark Guided versus Ultrasound-Guided Technique for Subclavian Vein Cannulation in Critically Ill Patients.

Background: Central Venous Access (CVA) is acommon requirement in the critically ill patient for avariety of indications including Central VenousPressure (CVP) monitoring, haemodialysis, placementof pulmonary artery catheters, cardiac pacing and foradministration of drugs especially vasoactive,chemotherapy agents and parenteral nutrition.Traditionally, Central Venous Catheter (CVC)placement is performed using Landmark (LM)technique and is associated with complications likearterial puncture, pneumothorax, hemothorax, airembolism, catheter embolism, and cardiac arrhythmias.Use of Ultrasound (US) is currently indicated forvarious clinical situations to reduce complication rate ofLM technique. Aim and Objectives: The purpose of thisstudy was to determine whether US guidance couldimprove the success rate, number of attempts, and rateof acute complications like inadvertent arterialpuncture, hematoma formation, and pneumothorax ofsubclavian venous catheterization. Material andMethods: Sixty patients in need of central venouscatheter were prospectively randomized in two groupsof 30 each. In the LM group patients were catheterizedusing the LM method and in US group patients werecatheterized by real-time US-guidance. Number ofattempts, success rate, access time and complicationslike accidental subclavian artery puncture, haematomaformation, pneumothorax, were recorded. p values<0.05 were considered statistically significant. Results:In the US group 30 (100%) of patients were successfullycannulated with the US guidance while the landmarktechnique was successful in 26 (86.66%) of patients. Inthe US group the success on first attempt was 83.33 %which was a significantly higher from 56.67% achievedin the LM group (p=0.025). The average number ofattempts for successful cannulation in the US group was1.16 ± 0.4, while in the LM group it was 1.56 ± 0.9 withstatistically significant difference (p=0.046). Accesstime was 27.26 ± 04.62 seconds in the US group, whilethe access time was significantly more in the LM group36.56 ± 17.35 seconds (p=0.0062). Conclusion: USguidance during subclavian vein catheterizationincreases overall and first attempt success, improvesaccess time with reduced average number of attemptsand complications.

A comparative study of supraclavicular versus infraclavicular approach for central venous catheterization in neurosurgical patients

Background: Central venous cannulation is a commonly performed procedure in neurosurgical patients to maintain the hemodynamic stability in the intraoperative period. It is used for infusion of intravenous fluids, vasopressors central venous pressure monitoring and detection of air embolism. Subclavian vein is commonly performed as there are minimal effects of positioning on it. Supraclavicular approach to subclavian vein cannulation is not as frequently employed as the infraclavicular approach. The purpose of this study was to compare the supraclavicular approach versus the infraclavicular approach in terms of number of attempts, success rate of catheterization and complications associated with the procedure.Methods: About 150 patients undergoing various neurosurgical procedures were enrolled in the study. They were divided into two groups. 75 patients underwent right supraclavicular catheterization of subclavian vein while as 75 patients underwent right infraclavicular catheterisation of the subclavian vein. The number of attempts for cannulation, success or failure of catheterization and any complications associated with the procedure or in the postoperative period were noted in each group. The data was compared between the two groups by using Chi-square test and Student’s Independent Samples T-test.Results: The right supraclavicular vein was successfully cannulated in 90.66% while as the right infraclaviclar vein was successfully cannulated in 96% of the patients (p >0.05). Malpositioning of catheter (threaded in contralateral subclavian) was noted in 4 patients in Group S and ipsilateral internal jugular vein in 2 patients. Pneumothorax was encountered in 1 patient in the group S undergoing supraclavicular subclavian vein cannulations while as subclavian arterial puncture was seen in 4 patients who underwent infraclavicular arterial puncture.Conclusions: There was no difference in successive cannulations between right the supraclavicular and right infraclaviclar veins. The rate of complications between the two approaches was comparable.

Síndrome do desfiladeiro torácico: uma revisão narrativa / Thoracic outlet syndrome: a narrative review

RESUMO A Síndrome do Desfiladeiro Torácico (SDT) é causada pela compressão do plexo braquial, artéria subclávia e veia subclávia na região do desfiladeiro torácico. Estas estruturas podem ser comprimidas entre a clavícula e a primeira costela ou por um número de variações anatômicas. A compressão neurológica é a forma mais comum da síndrome do desfiladeiro torácico. Complicações vasculares ocorrem com pouca frequência. Complicações arteriais geralmente resultam da compressão da artéria subclávia por costela cervical completa. As complicações venosas estão muitas vezes relacionadas à compressão muscular da veia subclávia. A forma neurogênica, anteriormente descrita, é a mais comum, constituindo mais de 95% dos casos. Já a forma venosa representa 2% a 3% e, a arterial, cerca de 1% dos casos. Fatores de risco incluem biótipo e variações individuais, como genética, idade e sexo. No Brasil, não há dados acerca da epidemiologia da SDT. Diante da suspeita de SDT é necessária uma avaliação clínica detalhada, seguida de exames complementares para elucidação da causa. O tratamento é direcionado de acordo com a etiologia e a presença ou não de complicações. A proposta do presente trabalho foi realizar uma revisão narrativa sobre a SDT, versando sobre sua etiologia, fisiopatologia, epidemiologia, avaliação clínica, exames complementares, diagnósticos diferenciais e tratamento.

ABSTRACT The Thoracic Outlet Syndrome (TOS) results from compression of the brachial plexus, the subclavian artery and the subclavian vein in the thoracic outlet region. This compression may take place between the clavicle and the first rib or by a number of anatomical variations. Neurological compression is the most common form of thoracic outlet syndrome. Vascular complications occur infrequently. Arterial complications usually result from compression of the subclavian artery by a complete cervical rib. Venous complications are often related to muscle compression of the subclavian vein. The neurogenic form, previously described, is the most common, constituting more than 95% of cases, while the venous represents 2% to 3%, and the arterial, about 1%. Risk factors include biotype and individual variations such as genetics, age and gender. In Brazil, there are no data on the epidemiology of TOS. Given the suspicion of TOS, a detailed clinical evaluation is necessary, followed by complementary exams to elucidate the cause. The treatment is directed according to the etiology and the presence or absence of complications. The purpose of this study was to perform a narrative review on TOS, focusing on its etiology, pathophysiology, epidemiology, clinical evaluation, complementary exams, differential diagnoses, and treatment.

One case of patient with bilateral ectopic subclavian vein catheterization / 中华烧伤杂志

One female patient aged 18 years, with severe burns and inhalation injury was admitted to our unit on June 5th, 2013. After admission, the right subclavian vein catheterization was performed for rapid fluid infusion against shock. Escharectomy on both upper extremities was planned to carry out and repaired with medium-thickness skin on right thigh 52 hours after injury. However, after general anesthesia, the right subclavian vein catheter was with poor fluid infusion, and the left subclavian vein catheterization was performed. Supraventricular tachycardia and decreased blood pressure occurred followed by fluid replacement and dilatation, cardiotonics, and diuretics. Postanesthetic 1.3 hours, the patient′s vital signs were stable, and the operation began. Postoperative chest X-ray film showed that distal ends of the left and right subclavian vein catheters were respectively located in the right atrium and the right internal carotid vein, and the catheters were removed immediately. This case suggests that clinical physician should be careful to prevent catheter heterotopia in subclavian vein catheterization, and postoperative routine chest X-ray examination is necessary to identify position of the catheter.

Ultrasonido para accesos vasculares centrales. Un concepto de seguridad que se renueva día a día: revisión / Ultrasound for central vascular access. A safety concept that is renewed day by day: review

Abstract Background: Ultrasound (US)-guided central venous catheterization is intended to reduce complications, enhance success rates on the first attempt, and increase accuracy, thus becoming a standard in clinical practice. Objectives: To review the relevant literature on the importance of US as a guide to central venous access and to describe the benefits of this tool and the impact of its use on the safety of the procedure. Methods: A narrative review of various medical literature databases and recognized guidelines (National Guideline Clearinghouse, New Zealand Guidelines, National Institute for Clinical Excellence, Cochrane, and JAMA). Results: High-quality evidence recommends US-guided inter nal jugular vein access as the preferred approach in routine practice. However, different other anatomical sites may be necessary for vascular access depending on the clinical setting. Related complications associated with landmark-guided techni ques range between 0.3% and 18.8% and depend on multiple conditions such as patient characteristics and access site. US has been associated with a reduction in the relative risk of complica tions, failed attempts, and failed first attempt of 57%, 86%, and 41%, respectively. Conclusion: US should be used routinely in central vascular access. Current evidence supports this recommendation for the internal jugular vein approach, but no so for the other approaches, in cases of difficult or failed access using conventional approaches.

Resumen Introducción: El catéter guiado por ultrasonido busca impactar en la incidencia de complicaciones, aumentar las tasas de éxito en el primer intento, e incrementar la precisión; convirtiéndose en estándar en la práctica clínica. Objetivo: Elaborar una revisión de la literatura más relevante sobre la importancia del ultrasonido (US) como guía para la canulación de accesos vasculares centrales y hacer una descripción sobre los beneficios de esta herramienta y cómo impacta en la seguridad del procedimiento Métodos: Revisión narrativa; se consultaron diferentes bases de datos, como National Guideline Clearinghouse, New Zeland Guidelines, Medline, NICE, Cochrane, JAMA. Resultados: El abordaje para un catéter venoso central que tiene suficiente evidencia para recomendar su uso rutinario guiado por US, es en vena yugular interna, pero no quiere decir que ésta deba prevalecer sobre situaciones en las cuales esté indicado un catéter venoso central por otra vía. Las complicaciones de las técnicas guiadas por referencias anatómicas oscilan entre 0,3% a 18,8%, por múltiples variables como la población de pacientes, sitio de inserción; se han impactado con el uso del US en reducción del riesgo relativo de complicaciones, intentos fallidos y fracaso primer intento en 57%, 86% y 41%, respectiva mente. Conclusión: El ultrasonido debe ser rutinario para obtener un acceso vascular central, la evidencia actual soporta esta reco mendación en vena yugular interna, no tanto así para los demás abordajes; en aquellos casos de canalización difícil o fallida por métodos convencionales, en cualquiera de las vías descritas hay que utilizar el ecógrafo como herramienta para garantizar el éxito.

Does the direction of J-tip of the guide-wire influence the misplacement of subclavian catheterization?

OBJECTIVE: Central venous catheter (CVC) misplacement can result in incorrect readings of the central venous pressure, vascular erosion, and intravascular thrombosis. Several studies have examined the correlation between the guidewire J-tip direction and misplacement rate. This study examined whether the guidewire J-tip direction (cephalad vs. caudad) affects the misplacement rate in right subclavian venous catheterization. METHODS: This prospective randomized controlled study was conducted between February 2016 and February 2017. The subjects were divided into two groups (cephalad group vs. caudad group) and the misplacement rate was compared according to guidewire J-tip direction in each group. RESULTS: Of 100 patients, the cephalad and caudad groups contained 50 patients each. The age, sex, and operator experience were similar in the two groups. In the cephalad group, misplacement of CVC insertion into the ipsilateral internal jugular vein occurred in two cases. In the caudad group, misplacement of CVC insertion into the contralateral subclavian vein occurred in one case, with loop formation in the brachiocephalic trunk in one case. Guidewire J-tip direction showed no significant correlation with CVC misplacement. CONCLUSION: The guidewire J-tip direction does not influence the rate of misplacement.

Ultrasound exam for differentiating guidewire's misplacement into brachial artery during PICC insertion through subclavian vein / 中国实用护理杂志

Objective Introducing ultrasound exam method for detecting accidental displacement of guidewire into brachial artery during one type of PICC placement. Methods Select 145 patients with PICC placement as objects of study. During procedure, use EKG guidance for localization. After successfully inserted the needle into a vein and threaded the guidewire through the needle, then apply ultrasound to show the guidewire image to verify whether or not the guidewire is advanced into brachial artery at any moment. After the procedure, a chest X-ray is taken for location confirmation. Results 144 patient's guidewire ultrasound images were seen inside the subclavian vein. One patient's guidewire ultrasound image was shown inside the subclavian artery, which confirms it was accidentally advanced into the brachial artery during insertion. The guidewire was removed immediately, only scant bleeding occurred. Conclusions By utilizing ultrasound to show the guidewire image inside subclavian vein, it will help differentiate if it is accidentally advanced into the brachial artery at any moments during PICC insertion. It assists avoiding complications after advancing the catheter. It is easy to perform and helpful for wide clinical use.

Clinical effect of ultrasound-guided axillary-subclavian vein catheterization / 临床麻醉学杂志

Objective To compare clinical effectiveness of real-time ultrasound-guided axillary-subclavian vein catheterization with that of the traditional technique.Methods A total of 142 patients who were intended to receive central venous catherization puncture,73 males and 69 females,aged 19-85 years,were randomly divided into two groups:traditional puncture of body-surface localization group (group T,n=71);real-time ultrasound-guided puncture group (group U,n=71),the probe was placed at the midline of the collarbone,30-40°horizontal to the clavicle,forming approximately a 60°angle between the longitudinal section of the probe and the coronal plane of the human body, showing the long axis of vein clearly,then in the long axis view puncture was performed.Time re-quired for catheterization,the number of needle advances and complications were recorded.The first-time success rate and the second-time success rate and failure rate were calculated.Results Puncture time of group U was significantly shorter than that of group T [(5.02±2.05)min vs (14.02±3.98) min,P<0.05].The first-time success rate of group U were higher than that of group T (95.8% vs 67.6%,P <0.05).The complication rate of group U was lower than that of group T (P<0.05). Catheter misplacements did not differ between the two groups.Conclusion Real-time ultrasound guided axillary-subclavian vein puncture is superior to the traditional technique and is worthy of clinical promotion.

Application of modified supra-clavicular subclavian vein puncture path in the patients with consciousness disorder / 局解手术学杂志

Objective To compare the practicability, reliability and safety of three paths of central venous puncture,namely internal jugular vein,modified supra-clavicular subclavian vein and subclavian vein,for patients with consciousness disorder.Methods The clinical data of 135 patients with consciousness disorder in department of neurology were retrospectively analyzed.These patients were comprised of 40 cases of internal jugular vein puncture(group J),58 cases of modified supra-clavicular subclavian vein puncture(group GS)and 37 cases of subclavian vein puncture(group S).The one-time success rate,total success rate,puncture and catheterization time and complications were compared among the three groups.Results The one-time success rate of group GS(89.7%)was higher than that of group J(77.5%)and group S(59.5%)with significant difference(P<0.05).There was no significant difference in the total success rate between group GS (94.8%)and group J(87.5%)(P>0.05),but they were higher than that of group S(70.3%)with significant difference(P<0.05). The puncture and catheterization time in group GS was shorter than that of group J and group S with significant difference(P<0.05).The to-tal incidence of complications of group GS(5.2%)was lower than that of group J(20%)and group S(29.7%)with significant difference (P<0.05).Conclusion Compared to internal jugular vein and subclavian vein, the modified supra-clavicular subclavian vein puncture path can adapt to more body positions,improve success rate and reduce complications in patients with consciousness disorder.

UNILATERAL BREAST EDEMA DUE TO SUBCLAVIAN VEIN COMPRESSION / Edema mamário unilateral resultante de compressão da veia subclávia

Unilateral breast edema may have different causes that vary from malignant to benign diseases. The  knowledge of the main etiologies, associated to a detailed clinical examination and to radiological findings, is important in order to establish the correct diagnosis and determine the appropriate management of the patient. This article will report the case of a patient with lung cancer who developed unilateral breast edema; the main differential diagnoses will also be discussed.

O edema mamário unilateral pode ter diferentes causas, que variam desde doenças malignas até benignas. O conhecimento das principais etiologias, associado ao exame clínico detalhado e aos achados radiológicos, é importante para que se estabeleça o diagnóstico correto, e para que se determine o manejo adequado do paciente. Neste artigo, será relatado o caso de uma paciente com câncer de pulmão que desenvolveu edema mamário unilateral; também serão discutidos os principais diagnósticos diferenciais.

Efecto del uso de ultrasonido en tiempo real en la inserción del catéter venoso central / Effect of ultrasound in real time in the insertion of central venous catheter

Resumen ANTECEDENTES: la colocación del catéter venoso central es una parte esencial en el tratamiento de los pacientes en muchos escenarios clínicos. El ultrasonido en tiempo real se ha convertido en una herramienta invaluable debido a su seguridad, disponibilidad y proporciona información detallada en relación con la anatomía de los órganos internos, en la colocación de catéteres venosos centrales favorece las tasas de éxito y disminuye el número de complicaciones. OBJETIVO: determinar si la colocación de catéter venoso central guiado por ultrasonido en tiempo real disminuye el número de complicaciones en comparación con la técnica por referencias anatómicas. MATERIAL Y MÉTODO: estudio observacional, ambispectivo, longitudinal en el que se seleccionaron adultos mayores de 18 años de edad que requirieron un catéter venoso central durante su hospitalización en el Hospital General Naval de Alta Especialidad (HOSGENAES) guiado por ultrasonido en tiempo real y por referencias anatómicas de enero de 2014 a febrero de 2016. Los datos se recabaron de los expedientes clínicos siempre y cuando estuvieran completos. Las variables observadas fueron el tipo de complicaciones, tipo de catéter, sitio de inserción, operador experto, servicio que instaló los catéteres venosos centrales, si fue de primera vez o subsecuente, número de intentos, accesos exitosos y los diagnósticos de ingreso, edad, género e índice de masa corporal. RESULTADOS: se incluyeron 464 pacientes de los que 351 (76%) fueron guiados por referencias anatómicas y en 113 (24%) por ultrasonido en tiempo real. Se reportaron 211 complicaciones, 84% en el grupo de referencias anatómicas y 16% en el grupo de ultrasonido en tiempo real con razón de momios (OR) de 2.36. La complicación más frecuente fue la de tipo mecánica, principalmente la mala colocación, en el grupo de referencias anatómicas representó 51% versus 12% en el grupo de ultrasonido en tiempo real con OR de 9.5. El 100% de los catéteres venosos centrales guiados por ultrasonido en tiempo real fueron exitosos vs 87% de los guiados por referencias anatómicas. CONCLUSIONES: el ultrasonido en tiempo real mejora las tasas de éxito, reduce el número de intentos y disminuye las complicaciones asociadas con la inserción de un catéter venoso central.

Abstract BACKGROUND: The placement of central venous catheter (CVC) is an essential part in the management of patients in many clinical scenarios. Ultrasonography in real time (USRT) has become an invaluable tool because of its safety and availability and provides detailed information regarding the anatomy of the internal organs, in the placement of central venous catheters (CVCs) encouraging success rates and decreasing the number of complications. OBJECTIVE: To determine whether the placement of central venous catheter guided by real-time ultrasound decreases the number of complications compared with the technique for anatomical references. MATERIAL AND METHOD: An observational, retrospective and prospective, longitudinal study was done selecting adults over 18 years old who required a CVC during their hospitalization at the Naval General Hospital of High Specialty (HOSGENAES), Mexico City, led by USRT and anatomical references from January 2014 to February 2016. Data were gathered from the files provided they were complete. The variables observed were the kind of complications, type of catheter insertion site, skilled operator, service that installed the CVCs, if it was first or subsequent, number of attempts, successful access and admission diagnoses, age, gender and body mass index (BMI). RESULTS: Four hundred sixty-four patients were included, of which 351 (76%) were guided by anatomical and 113 (24%) by USTR references. A total of 211 complications occurred; 84% in the group of anatomical references and 16% were reported in the group USTR with OR of 2.36. The most common complication was mainly mechanical type misplacement accounting for 51% in the group of anatomical references versus 12% in the USRT with OR of 9.5375. The 100% of CVCs guided by USTR were successful vs 87% guided by anatomical references. CONCLUSIONS: Ultrasonography in real time improves success rates, reduces the number of attempts and reduces complications associated with the insertion of a central venous catheter.

Clinical study of Arteriovenous needle used in rescuing patients with hemorrhagic shock / 中国基层医药

Objective To evaluate the clinical value of subclavian vein puncture with 16 G arteriovenous indwelling needle for emergency treatment of hemorrhagic shock,so as to provide a new approach for the rapid establishment of deep venous passage.Methods 80 patients with acute hemorrhagic shock were randomly divided into patients with arteriovenous indwelling needle group (catheter group) and conventional guide wire deep vein puncture group(routine puncture group),40 cases in each group.The two groups were treated with supraclavicular subclavian vein puncture.The operation time,success rate of the first puncture,puncture times and rehydration rate,incidence of complications were observed in the two groups.Results The operation time of indwelling needle group was (62 ±22)s,which was significantly shorter than (672 ± 178)s of the conventional puncture group,there was significant difference between the two groups (t =15.062,P =0.000).The first time success rate of puncture in the indwelling needle group was 70％ (28 cases),which in the conventional group was 80％ (32 cases),the difference was not statistically significant(x2 =1.067,P =0.439),all patients were in 3 attempts in successful puncture.The velocity of infusion of 500 mL hydroxyethyl starch in the indwelling needle group was (198 ± 51)s,which was better than (456 ± 86)s in the conventional puncture group,the difference between the two groups was statistically significant (t =9.318,P =0.000).The two groups had no deep vein puncture related complications.Conclusion Arteriovenous indwelling needle by supraclavicular subclavian vein puncture with conventional guide wire supraclavicular subclavian vein puncture catheter can be used for emergency treatment of hemorrhagic shock,but the indwelling needle group in the operation time and velocity is superior to conventional guide wire group,more suitable for the rescue of patients with acute hemorrhagic shock time is pressing,stay with stable circulation can be through the guide wire inserted catheter indwelling subclavian vein catheter.

Pneumothorax related to subclavian vein puncture: analysis of the causes in 47 patients / 介入放射学杂志

Objective To investigate the risk factors that may induce pneumothorax resulted from subclavian vein puncture during interventional therapy for arrhythmia.Methods The clinical data of 4 351 patients with heart disease,who were admitted to Wuhan Asia Heart Disease Hospital,China,during the period from January 2010 to January 2014 to receive subclavian vein puncture for the performance of radiofrequency catheter ablation or pacemaker implantation,were retrospectively analyzed.The gender,age,presence of chronic obstructive pulmonary disease (COPD) and the shape of clavicle of patients who developed pneumothorax were analyzed,and their relationships with the occurrence of pneumothorax were evaluated.Results Of the 4 351 patients,47 patients developed pneumothorax(1.08％),their age was 12-72 years old with a mean of (47.1±18.4) years old.Among the 47 patients,37 patients were females (78.7％).The angle between clavicle and sternum ＜60°(oblique clavicle) was seen in 27 patients,coexisting COPD was seen in 2 patients.The occurrence of pneumothorax was strikingly higher in females than that in males (OR=2.7,95％ CI=1.4-5.2).In patients with oblique clavicle the risk of pneumothorax was obviously increased (OR=3.5,95％ CI=1.6-7.9) and in patients with COPD the probability of pneumothorax was remarkably increased (OR=2.3,95％CI=1.2-4.7).No special treatment was employed in 5 pneumothorax patients,and the pneumothorax was absorbed by itself.In 19 patients,the pneumothorax was relieved through thoracic puncture and suction.Closed drainage of thoracic cavity was employed in 23 patients.All patients were discharged from hospital with complete rehabilitation.Conclusion Clinically,pneumothorax has been an important clinical problem in interventional therapy.In female patients and in patients who have oblique clavicle or coexisting COPD,pneumothorax is more likely to occur when they receive subclavian vein puncture.