Ultrasound for Localization of Central Venous Catheter: A Good Alternative to Chest X-Ray?

BACKGROUND: Chest radiography after central venous catheter (CVC) insertion is the main method of verifying the catheter location. Despite the widespread use of radiography for detecting catheter position, x-ray may not always be readily available, especially in the operating room. OBJECTIVES: We aimed to compare contrast-enhanced ultrasonography (CEUS) and chest radiography for detecting the correct location of CVCs. METHODS: One hundred sixteen consecutive patients with indications for CVC before cardiac surgery were enrolled in this observational study. After catheter insertion, CEUS was performed. Portable radiography was obtained postoperatively in the intensive care unit. Sensitivity, specificity, and predictive values were determined by comparing the ultrasonography results with radiographic findings as a reference standard. RESULTS: Chest radiography revealed 16 CVC misplacements: two cases of intravascular and 14 cases of right atrium (RA) misplacement. CEUS detected 11 true catheter malpositionings in the RA, while it could not recognize seven catheter placements correctly. CEUS showed two false RA misplacements and five falsely correct CVC positions. A sensitivity of 98% and specificity of 69% were achieved for CEUS in detecting CVC misplacements. Positive and negative predictive values were 95% and 85%, respectively. The interrater agreement (kappa) between CEUS and radiography was 0.72 (P < 0.001). CONCLUSIONS: Despite close concordance between ultrasonography and chest radiography, CEUS is not a suitable alternative for standard chest radiography in detecting CVC location; however, considering its high sensitivity and acceptable specificity in our study, its usefulness as a triage method for detecting CVC location on a real-time basis in the operating room cannot be ignored.

Comparing the prevalence of chronic pain after sternotomy in patients undergoing coronary artery bypass grafting using the internal mammary artery and other open heart surgeries.

BACKGROUND: The prevalence of chronic postoperative pain after cardiac surgery has been reported from 17% to 56%. OBJECTIVES: We aimed to compare the prevalence of postoperative pain between patients who had undergone CABG using the internal mammary artery (IMA) and those who had undergone other cardiac surgeries including CABG using the saphenous vein or cardiac valvular surgeries. PATIENTS AND METHODS: In this cohort study, medical records of 188 patients were evaluated and divided into two equal groups (94 in each group); patients who had undergone CABG using the IMA (IMA group) and those who had undergone other cardiac surgeries using the saphenous vein or other cardiac valvular surgeries (non-IMA group). The patients' data were recorded in a self-structured questionnaire and then phone interviews were performed 3 months after the operations regarding the rate of postoperative pain. The severity of chronic pain was rated based on the numerical rating pain scale. RESULTS: The two groups differed significantly regarding the prevalence of pain (P = 0.023). In the IMA group, 83 (88.3%) patients experienced pain lasting for more than three months compared to 71 (75.5%) patients in non-IMA group. The two groups differed significantly with respect to the severity of chronic pain after cardiac surgery via sternotomy (P = 0.001). The groups did not differ significantly regarding the effects of chronic pain on their sleep, referral to a physician, and drug consumption to alleviate their pain. The IMA group experienced more complications at work and during their occupational activity. CONCLUSIONS: The rate and severity of chronic pain after cardiac surgery via sternotomy was higher in patients undergoing CABG with separation of IMA for revascularization.

Determination of the incidence and severity of hoarseness after cardiac surgery.

BACKGROUND: The aim of the study was to determine the incidence and severity of hoarseness and vocal cord dysfunction in 200 patients undergoing open heart surgery in Shiraz-Iran. MATERIAL/METHODS: This study involved prospective evaluation of 200 patients who underwent open heart surgery during the year 2003 in Shiraz University hospitals. All patients received the same standard anesthetic technique. In post-operative course, all patients were electively ventilated for variable periods depending on several factors, at least until the morning after surgery. All patients underwent direct laryngoscopy immediately after extubation by the otolaryngologist, and the existence and grade of hoarseness was evaluated on a four-point scale 6 and 12 hours after extubation. RESULTS: Two hundred patients, 64.5% male and 35.5% female, with a mean age of 56.7 (S.D. = 5.2) were evaluated. CABG was performed most frequently and the mean duration of cold perfusion was 122 minutes (S.D. = 15). CVP insertion, endotracheal intubation, sternotomy, and hypothermia were performed in all patients. Hoarseness was found to be present in 17% of patients; all but one were rated to be grade one on the four-point scale. However, laryngoscopy did not reveal anything specific. CONCLUSIONS: The incidence of hoarseness in this study was 17%; similar series reported as high as 32%. Vocal cord dysfunction never occurred in our study and hoarseness probably resulted from intubation trauma. Although we found no case of nerve injury and cord dysfunction, vocal cord palsy as a rare cause of respiratory insufficiency in chest and neck surgeries must never be overlooked.

The relief of anxiety: comparative study--air plane flying vs anesthesia.

BACKGROUND: Airplane Flying and anesthesia are both not entirely safe. Passengers and patients have the right not to be endangered during flight or anesthesia. Flying and anesthesia has always been associated with anxiety in passengers and patients. OBJECTIVE: This study was undertaken to compare the anxiety between passengers to fly and patients to receive anesthesia. METHODS: One hundred and eighty persons were randomly selected and divided into six equal groups. Pilots and flight crew; anesthetist, resident of anesthesiology and nurse anesthetists; people who had flown but without any history of anesthesia; people without any experience of flight or anesthesia; people with previous experiences of both the flight and anesthesia and finally people with a previous history of anesthesia but without any experience of flight as Groups 1 to 6 respectively. A questionnaire was used to evaluate the level of anxiety during both the flight and anesthesia. RESULTS: All six groups had significantly more anxiety from anesthesia than flying (p < 0.05) except in group 5 (p = 0.460). Anxiety of flying was significantly less in pilots and flight crews (group 1) when compared with other groups (p < 0.004). The anxiety of anesthesia was significantly less in anesthetist team when compared with those who has not experienced general anesthesia. People who had not experienced anesthesia showed more fear about anesthesia than those who had experienced general anesthesia (p < 0.002). CONCLUSION: The results showed that having enough information about flying causes less anxiety just as preoperative visits help the patient to undergo a more comfortable anesthesia.