Lower Double-Wall Puncture Rate During Ultrasound-Guided Internal Jugular Vein Cannulation Using Sharper, Narrower-Gauge, and/or Length-Optimized Needles: A 6-Year Quality Improvement Clinical Series in Adult Patients.

Background: During internal jugular vein (IJV) cannulation, needle tip injury to vulnerable subjacent cervical anatomic structures can be prevented if the cannulating needle tip is not permitted, even momentarily, to penetrate the deep portion of the IJV wall, an event known as double-wall puncture (DWP), also called posterior wall puncture. Methods: We conducted a 6-year ultrasound-guided IJV cannulation quality improvement project, seeking to minimize the occurrence of DWP in 228 adult patients using needles of different gauge and tip sharpness. Most needles were length-optimized to the distance between the skin puncture site and the IJV mid-lumen for a selected angle of needle insertion by (1) using a nylon screw-on needle stop or (2) using a cannulating needle that already had the desired shaft length. Results: Standard central venous cannulation kit needles were long enough to reach or traverse the deepest portion of the IJV wall in nearly all patients. Use of extra-sharp, smaller-diameter needles in place of standard needles was associated with a 26.3% relative reduction in DWP rate. Use of needles length-optimized to reach only the IJV mid-lumen was associated with a 78.4% relative reduction in DWP rate. A 0% DWP rate was attained using length-optimized 21-gauge extra-sharp needles and length-optimized 20-gauge needles of intermediate sharpness. Conclusion: The 9.2% DWP rate achieved during this project was approximately half the rate reported at the time of project inception. Use of length-optimized, sharper, narrower-gauge cannulating needles may help avoid DWP during ultrasound-guided IJV cannulation.

Development of effective prophylaxis against intraoperative carcinoid crisis.

STUDY OBJECTIVE: The prophylactic use of a preoperative, intraoperative, and postoperative high-dose continuous octreotide acetate infusion was evaluated for its ability to minimize the incidence of carcinoid crises during neuroendocrine tumor (NET) cytoreductive surgeries. DESIGN: A retrospective study was approved by the institutional review boards at Ochsner Medical Center-Kenner and Louisiana State University Health Sciences Center. SETTING: Ochsner Medical Center-Kenner operating room and multispecialty NET clinic. PATIENTS: One hundred fifty consecutive patients who underwent a total of 179 cytoreductive surgeries for stage IV, small bowel NETs. INTERVENTIONS: All patients received a 500-µg/h infusion of octreotide acetate preoperatively, intraoperatively, and postoperatively. MEASUREMENTS: Anesthesia and surgical records were reviewed. Carcinoid crisis was defined as a systolic blood pressure of less than 80mm Hg for greater than 10minutes. Patients who experienced intraoperative hypertension or hypotension, profound tachycardia, or a "crisis" according to the operative note were also reviewed. MAIN RESULTS: One hundred sixty-nine (169/179; 94%) patients had normal anesthesia courses. The medical records of 10 patients were further investigated for a potential intraoperative crisis using the aforementioned criteria. Upon review, 6 patients were determined to have had a crisis. The final incidence of intraoperative crisis was 3.4% (6/179). CONCLUSIONS: A continuous high-dose infusion of octreotide acetate intraoperatively minimizes the incidence of carcinoid crisis. We believe that the low cost and excellent safety profile of octreotide warrant the use of this therapy during extensive surgical procedures for midgut and foregut NETs.

Circumferential adjustment of ultrasound probe position to determine the optimal approach to the internal jugular vein: a noninvasive geometric study in adults.

Circumferential adjustment of the position of a two-dimensional ultrasound (US) probe around the neck has been recommended as a strategy for reducing the potential for unintentional common carotid artery puncture during internal jugular venous (IJV) cannulation. We obtained multiple high-resolution US images bilaterally from the necks of 107 adult subjects and analyzed these to determine the degree to which this strategy permits identification of a pathway from the skin to the IJV that minimizes venoarterial overlap while maximizing venous target (angular) width. The method consistently permitted identification of an approach to the IJV superior to that obtainable with any one of four popular surface anatomy-based ("blind") approaches and was even more powerful if used in concert with a US-guided 1) adjustment of the degree of head rotation, 2) choice between a high and low approach, and 3) choice between the right and left IJV. Use of a high-resolution US imaging device also permitted identification of the precise boundaries of additional cervical anatomic structures (nontarget vessels, lymph nodes, and the thyroid gland) potentially relevant to selection of an optimal approach to the IJV.