Ultrasound-guided placement of a midline catheter in a patient with extensive postburn contractures: A Case report.

RATIONALE: Obtaining venous access in a patient with extensive postburn scar contractures is a challenge. PATIENT CONCERNS: A 39-year-old woman suffered a burn 2 years previously with a total body surface area burn of 93%, and a burn index of 85. Reconstructive surgery was previously performed 39 times. Split-thickness skin grafting to the neck was planned. She had no accessible peripheral veins. DIAGNOSIS: Difficult venous access due to excessive burn scar contractures. INTERVENTIONS: Central venous catheterization was considered impossible even with ultrasound guidance. We placed a midline catheter for intraoperative venous access in a patient with extensive burn scar contractures. The midline catheter is a peripheral venous catheter placed in an arm vein. OUTCOMES: We successfully placed a midline catheter in the right brachial vein. This catheter was used for 24 days without difficulty. LESSONS: The midline catheter is a viable choice in patients with difficult vascular access due to extensive postburn scar contractures.

Predictors for sustained new-onset atrial fibrillation in critically ill patients: a retrospective observational study.

PURPOSE: Although new-onset atrial fibrillation (AF) is frequently observed in the intensive care unit (ICU), the incidence and predictors for sustained new-onset AF have not been investigated, except for cardiac surgery patients. We have evaluated potential predictors for sustained new-onset AF in a mixed ICU. METHODS: In this retrospective observational study, we screened non-cardiac surgery patients who were admitted to the ICU between January 2010 and December 2013 and had been hospitalized for > 24 h in the ICU. We collected information about heart rhythm 6 h after the onset of AF. We compared detailed patient characteristics between patients with sinus rhythm (SR) and those with sustained AF at 6 h after the onset of AF. Additionally, we applied variable selection using backward elimination based on Akaike's Information Criterion (AIC). Calibration was performed based on the Hosmer-Lemeshow test. RESULTS: New-onset AF occurred in 151 of 1718 patients and 99 patients converted to SR at 6 h. Backward elimination identified predictors as follows (AIC = 175.3): CHADS2 score, elective surgery, infection on ICU admission, serum potassium > 4.0 mmol/L, male sex, mechanical ventilation, and diagnostic grouping. The model showed good calibration for sustenance of AF at 6 h after the onset using the Hosmer-Lemeshow Chi-square value of 4.36 (degrees of freedom = 4, p = 0.360) indicating a good fit. CONCLUSIONS: These predictors might be useful in future interventional studies to identify patients who are likely to sustain new-onset AF.

The impact of sustained new-onset atrial fibrillation on mortality and stroke incidence in critically ill patients: A retrospective cohort study.

PURPOSE: The purpose of the study is to evaluate the impact of sustained new-onset AF on mortality and the incidence of stroke in critically ill non-cardiac surgery patients. MATERIAL AND METHODS: This was a retrospective cohort study of non-cardiac surgery patients with new-onset AF conducted in a general intensive care unit. We compared patients remaining in AF with those restored to sinus rhythm (SR) at 6h after the onset of AF and conducted multivariable logistic regression analysis for in-hospital mortality. We also examined the impact of the cumulative time of AF duration in the first 48h on hospital outcomes. RESULTS: New-onset AF occurred in 151 of 1718 patients (9%). Patients with sustained AF after 6h (34% of 151 patients included) experienced greater in-hospital mortality than patients with SR at 6h (37% vs. 20%, p=0.033). Multivariable logistic regression analysis confirmed the association between AF at 6h and in-hospital mortality (adjusted odds ratio, 3.14; 95% confidence intervals, 1.28-7.69; p=0.012). Patients with longer AF duration had greater in-hospital mortality (p=0.043) and in-hospital ischemic stroke incidence (p=0.041). CONCLUSION: Sustained new-onset AF is associated with poor outcomes.

[Use of the i-gel for Tracheostomy in a Patient with Neck Deformity and Tracheal Stenosis].

We report a successful use of the i-gel for tracheostomy in a patient with severe neck deformity and tracheal stenosis. A 20-year-old man, 142 cm, 22 kg, was scheduled for tracheotomy. He had tracheal stenosis with hypoxemia, due to the pressure from the brachiocephalic artery, associated with severe progression of symptomatic scoliosis and thoracic deformity. Using a fiberoptic bronchoscope, we confirmed that there was no upper airway obstruction. After induction of anesthesia, facemask ventilation was easy. The i-gel was easily inserted, and fiberscope-aided tracheal intubation through the i-gel was attempted, but decided not to intubate the trachea, due to the degree of stenosis. Tracheostomy was performed, while a clear airway was maintained by the i-gel. We consider that the i-gel has a potential role for tracheostomy in a patient with neck deformity and tracheal stenosis.