Safety and Efficacy of Percutaneous Translumbar Inferior Vena Cava Catheters: A Systematic Review and Meta-Analysis.

PURPOSE: To examine the reported adverse events associated with inferior vena cava (IVC) catheterization and investigate the reasons for discrepancies between reports. MATERIALS AND METHODS: Cochrane Library trials register, PubMed, Embase, and Scopus databases were systematically searched for studies that included any terms of IVC and phrases related to catheters or central access. Of the 5,075 searched studies, 137 were included in the full-text evaluation. Of these, 37 studies were included in the systematic review, and the adverse events reported in 16 of these 37 identified studies were analyzed. An inverse-variance random-effects model was used to conduct the meta-analysis. Outcomes were summarized by the incidence rate (IR) and 95% CI. RESULTS: Compared with that of catheters <10 F in size (IR, 0.08; 95% CI, 0.03-0.12), the incidence of catheter-related infections per 100 catheter days was 0.2 more for catheters ≥10 F in size (IR, 0.28; 95% CI, 0.25-0.31). In addition, dual-lumen catheters showed 0.13 more malfunction per 100 catheter days (IR, 0.27; 95% CI, 0.16-0.37) than that shown by single-lumen catheters (IR, 0.14; 95% CI, 0.09-0.19). Both differences were statistically significant. Other adverse events were malposition (IR, 0.04; 95% CI, 0.04-0.05), fracture (IR, 0.01; 95% CI, 0.00-0.02), kinking (IR, 0.01; 95% CI, 0.00-0.01), replaced catheter (IR, 0.2; 95% CI, 0.1-0.31), removal (IR, 0.13; 95% CI, 0.1-0.16), IVC thrombosis (IR, 0.01; 95% CI, 0.00-0.03), and retroperitoneal hematoma (IR, 0.01; 95% CI, 0.00-0.01), all per 100 catheter days. CONCLUSIONS: Translumbar IVC access is an option for patients with exhausted central veins. Small-caliber catheters cause fewer catheter-related infections, and single-lumen catheters function longer.

A systematic review of the quality of cardiovascular surgery studies that extracted data from the MAUDE database.

OBJECTIVE: To investigate opportunities and limitations of using the Manufacturer and User Facility Device Experience (MAUDE) database for cardiovascular surgery research, we analyzed the quality of studies having ever used MAUDE, in the field of cardiovascular surgery. METHODS: We systematically searched the Cochrane Library, PubMed, EMBASE, and Google Scholar for randomized and nonrandomized studies, from inception to July 2019. Two authors evaluated the quality of the retrieved observational studies, according to the National Institutes of Health quality assessment tool for either case series or cross-sectional studies. These tools quantify the quality of case series and cohorts/cross-sectional studies, respectively, with nine and 14 queries. RESULTS: Fifty-eight studies were included in the final qualitative review. Of 58 identified studies, 32 were case series, 8 were abstracts of case series, and 13 were reviews or case discussion with an included series from MAUDE. Also, five articles were cross-sectional studies. Of the 32 formal case series, 26 (81%) were found to have poor quality. The most common reasons for a poor quality designation included a lack of consecutive participants, undetermined comparability of participants, and undetermined follow-up adequacy. Only one out of five cross-sectional studies had fair quality; four others were evaluated as poor quality studies. CONCLUSIONS: Cardiovascular surgery studies using the MAUDE database, whether case series or cross-sectional design, are mostly of poor quality. Their low quality is partly caused by poor study design, but mainly by intrinsic limitations to the MAUDE database: cases recruited are not consecutive; patient characteristics are not detailed enough to allow a meaningful comparison of patient characteristics between different patient entries; outcome measures are unclear; there is a limited follow-up; and time-to-event data are lacking. We conclude that the quality of cardiovascular surgery publications that rely on data from MAUDE could be improved if investigators were to extract all relevant data points from MAUDE entries, then apply standard quality assessment tools in compiling and reporting the data. MAUDE might be improved if it used medical case report standards during the process of reporting and indexing adverse events. To calculate the incidence rate of any adverse event, all event-free cases, as well as all adverse events in patients using a device, are required. Neither of these two variables is available in the MAUDE at the time of writing.

A systematic review and meta-analysis of predilation and postdilation in transfemoral carotid artery stenting.

OBJECTIVE: In this review, we evaluate the short-term impact of different ballooning combinations on hemodynamic instability neurologic events, and mortality associated with carotid artery stenting. METHODS: We used a search strategy to identify studies in the Cochrane Library trials register, PubMed, EMBASE, Google Scholar, and the US National Library of Medicine clinical trial databases up to May 2019. Studies reporting either hemodynamic instability, neurologic events, or mortality were included according to the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-analysis. Fixed and random models were used to summarize the effects. RESULTS: Of seven included cohort studies for qualitative review, six were selected for meta-analysis. Patients without postdilation had significantly less hemodynamic instability in the random effects model (risk ratio, 0.53; 95% confidence interval, 0.37-0.77; P = .001). Regardless of the dilation type, the overall summary effect in the fixed model showed a significant decrease in the risk of developing short-term neurologic events (risk ratio, 0.67; 95% confidence interval, 0.47-0.97; P = .03). Last, the exclusion of either of the two dilation techniques had no significant effect on mortality. CONCLUSIONS: Avoiding postdilation reduces perioperative hemodynamic instability and this benefit lasts at least up to 30 days. Regardless of the type, fewer dilations during carotid artery stenting possibly decreases the neurologic events during and 30 days after the procedure. The data also suggest that the residual stenoses above current practiced standard may provide a safer threshold to prompt postdilation. Statements about the long-term effects of dilation techniques requires more study.

Timing to perform VATS for traumatic-retained hemothorax (a systematic review and meta-analysis).

PURPOSE: In this systematic review, we analyzed the optimal time range to evacuate traumatic-retained hemothorax using video-assisted thoracoscopic surgery (VATS). METHODS: We searched PubMed, EMBASE, the Cochrane Register of Controlled Trials, Google Scholar, and the U.S. National Library of Medicine clinical trials database up to February 2019. Randomized controlled trials (RCTs) and observational studies with relevant data were included. Data were extracted from studies that reported the success, mortality, or length of hospital stay (LOS) after using VATS during at least two out of three of our time-ranges of interest: days 1-3 (group A), days 4-6 (group B), and day 7 or later (group C). RESULTS: Six cohort studies with 476 total participants were included in the meta-analysis. The patients in group A had a significantly higher success rate than those in group C (RR = 0.42; 95% CI = 0.21-0.84, p = 0.01). The total LOS for patients whose retained hemothorax was evacuated in group A was 4.7 days shorter than that for those in group B (95% CI = - 5.6 to - 3.8, p = 0.006). Likewise, group B patients were discharged 18.1 days earlier than group C patients (95% CI = - 22.3 to - 14, p < 0.001). Short-term mortality was not decreased by early VATS. CONCLUSIONS: Our results indicate that VATS should be considered within the first three days of admission if this intervention is the clinician's choice to evacuate a traumatic-retained hemothorax. Protocol registration number in PROSPERO: CRD42017046856.

Intranasal Lidocaine for Primary Headache Management in Emergency Department; a Clinical Trial.

INTRODUCTION: Most of the headache cases only require pain management in emergency department (ED). The present study aimed to evaluate the efficacy of intranasal lidocaine in this regard. METHOD: In this clinical trial, adult patients with primary headache were randomly treated with 7.5 mg intravenous (IV) chlorpromazine and 1 ml intranasal lidocaine 2% (treatment) or normal saline 0.9% (placebo), and were compared 5, 15, and 30 minutes later regarding success rate using SPSS 21. RESULT: 100 patients were assigned to either treatment or placebo group. Number needed to treat of intranasal lidocaine at 5, 15, and 30 minutes were 4 (95% CI: 2.2 - 6.6), 3 (95% CI: 1.7 - 3.5), and 4 (95% CI: 2.3 - 15.9), respectively. These measures for absolute risk reduction were 30 (95% CI: 15.2 - 44.8), 44 (95% CI: 28.7 - 59.3), and 26 percent (95% CI: 6.3 - 44.3), respectively. Pain relapse occurred in 16% of treatment and 11% of control group within 1 hour of treatment (p = 0.402). CONCLUSION: It seems that, intranasal lidocaine along with IV chlorpromazine could result in more successful and faster management of primary headaches in ED.

Anterograde catheterization of severe tracheal stenosis as a difficult airway management option, followed by emergent tracheostomy (a case report).

BACKGROUND: To describe the successful management of a patient with severe dyspnea and hypoxia due to tracheal stenosis by the application of a novel bridging technique-anterograde tracheal catheterization-prior to tracheostomy. CASE PRESENTATION: A 55-year-old woman entered the Emergency Department with severe dyspnea, tachypnea, and stridor and a pulse oximetry reading of 60 %. An attempt at intubation failed because of tracheal stenosis discovered 3-4 cm distal to the vocal cords, which had been formed as a complication of intubation the previous month. Cricothyrotomy could not be applied for failed airway management because the stenosis had formed distal to the cricothyroid membrane. Laryngeal mask airway ventilation did not improve the oxygenation to more than an arterial oxygen saturation (SpO2) of 70 %. Thus, anterograde insertion of a 12-F double-lumen central venous catheter was attempted, which sealed the 2-mm orifice of the stricture. Bag-valve-mask ventilation with this latter mode provided 80 % saturation as a bridge to an emergent bed-side tracheostomy. CONCLUSIONS: "Anterograde tracheal catheterization" appears to be a relatively effective and easy-to-perform option for oxygenation in such tracheal stenosis cases before a definite but time-consuming tracheostomy can secure the airway.

"Anterior convergent" chest probing in rapid ultrasound transducer positioning versus formal chest ultrasonography to detect pneumothorax during the primary survey of hospital trauma patients: a diagnostic accuracy study.

BACKGROUND: Occult pneumothorax represents a diagnostic pitfall during the primary survey of trauma patients, particularly if these patients require early positive pressure ventilation. This study investigated the accuracy of our proposed rapid model of ultrasound transducer positioning during the primary survey of trauma patients after their arrival at the hospital. METHODS: This diagnostic trial was conducted over 12 months and was based on the results of 84 ultrasound (US) exams performed on patients with severe multiple trauma. Our index test (US) was used to detect pneumothorax in four pre-defined locations on the anterior of each hemi-thorax using the "Anterior Convergent" approach, and its performance was limited to the primary survey. Consecutively, patients underwent chest-computed tomography (CT) with or without chest radiography. The diagnostic findings of both chest radiography and chest ultrasounds were compared to the gold-standard test (CT). RESULTS: The diagnostic sensitivity was 78 % for US and 36.4 % for chest radiography (p < 0.001); the specificity was 92 % for US and 98 % for chest radiography (not significant); the positive predictive values were 74 % for US and 80 % for chest radiography (not significant); the negative predictive values were 94 % for US and 87 % for chest radiography (not significant); the positive likelihood ratio was 10 for US and 18 for chest radiography (p = 0.007); and the negative likelihood ratio was 0.25 for US and 0.65 for chest radiography (p = 0.001). The mean required time for performing the new method was 64 ± 10 s. An absence of the expected diffused dynamic view among ultrasound images obtained from patients with pneumothorax was also observed. We designated this phenomenon "Gestalt Lung Recession." CONCLUSIONS: "Anterior convergent" chest US probing represents a brief but efficient model that provides clinicians a safe and accurate exam and adequate resuscitation during critical minutes of the primary survey without interrupting other medical staff activities taking place around the trauma patient. The use of the new concept of "Gestalt Lung Recession" instead of the absence of "lung sliding" might improve the specificity of US in detecting pneumothorax.

Using an Artificial Neural Networks (ANNs) Model for Prediction of Intensive Care Unit (ICU) Outcome and Length of Stay at Hospital in Traumatic Patients.

INTRODUCTION: Currently applications of artificial neural network (ANN) models in outcome predicting of patients have made considerable strides in clinical medicine. This project aims to use a neural network for predicting survival and length of stay of patients in the ward and the intensive care unit (ICU) of trauma patients and to obtain predictive power of the current method. MATERIALS AND METHODS: We used Neuro-Solution software (NS), a leading-edge neural network software for data mining to create highly accurate and predictive models using advanced preprocessing techniques, intelligent automated neural network topology through cutting-edge distributed computing. This ANN model was used based on back-propagation, feed forward, and fed by Trauma and injury severity score (TRISS) components, biochemical findings, risk factors and outcome of 95 patients. In the next step a trained ANN was used to predict outcome, ICU and ward length of stay for 30 test group patients by processing primary data. RESULTS: The sensitivity and specificity of an ANN for predicting the outcome of traumatic patients in this study calculated 75% and 96.26%, respectively. 93.33% of outcome predictions obtained by ANN were correct. In 3.33% of predictions, results of ANN were optimistic and 3.33% of cases predicted ANN results were worse than the actual outcome of patients. Neither difference in average length of stay in the ward and ICU with predicted ANN results, were statistically significant. Correlation coefficient of two variables of ANN prediction and actual length of stay in hospital was equal to 0.643. CONCLUSION: Using ANN model based on clinical and biochemical variables in patients with moderate to severe traumatic injury, resulted in satisfactory outcome prediction when applied to a test set.

Crisis management aspects of bam catastrophic earthquake: review article.

BACKGROUND: Bam earthquake was the most catastrophic natural disasters in recent years. The aim of this study was to review different aspects of crisis management during and after the catastrophic earthquake in Bam City, Iran. METHODS: Data needed for this systematic review were collected through searching PubMed, EMBASE and SID databases, for the period from 2003 to 2011. Keywords included earthquake, Iran and Bam earthquake. The data were summarized and were analyzed using Content Analysis. RESULTS: Out of 422 articles, 25 articles were included in the study. Crisis Management aspects and existing pitfalls were classified into seven categories including planning and organization, human resource management, management of logistics, international humanitarian aids, field performance of the military and security forces, health and medical service provision, and information management. Positive aspects and major pitfalls of crisis management have been introduced in all the mentioned categories. CONCLUSION: The available evidence indicated poor crisis management during Bam earthquake that resulted in aggravating the losses as well as diminishing the effect of interventions. Thus, concerning the importance of different aspects of the crisis management and the high prevalence of disasters in Iran, the observed vulnerability in disaster management process should be addressed.

Trauma-related Therapeutic Procedures at Shohada Trauma Center in Tabriz.

BACKGROUND: To decrease the burden of injuries it is essential to have an overview of trauma patterns and its management at regional trauma centers. OBJECTIVES: The aim of this study was to investigate some patterns of trauma and trauma-related therapeutic interventions at our trauma center. MATERIALS AND METHODS: In a cross-sectional study, 19530 trauma cases admitted to the emergency department and hospital wards of Shohada University Hospital during 2007-2008 were assessed. RESULTS: Of the 19530 trauma cases, 14960(76.7%) were males. Mean (SD) of age was 31(19.9) years. The elderly aged 65 and above, comprised 10% (1953) of the participants; while 44 were infants. Falls and traffic injuries were the most common cause of injuries among trauma patients. Most of the mortalities were men comprising 74% of the 57 deaths. Reduction of fractures and dislocations were the most common types of operations among trauma patients. CONCLUSIONS: Young men form the target group for possible interventions to decrease the burden of trauma following falls and traffic accidents.

Ventricular tachycardia due to flumazenil administration.

Flumazenil is one of imidazo-benzodiazepine (Anexate) which has been generally used as benzodiazepine competitive antagonist for the treatment of benzodiazepine intoxication during recent decades. Some has recommended diagnostic usage in ICU as well, for suspected benzodiazepine intoxicated cases. In this study we present a patient intoxicated with lorazepam who developed a ventricular tachycardia after receiving flumazenil as therapeutic mean, though the attack was appropriately terminated by administration of a bolus dose of Amiodarone. We believe that the ventricular tachycardia onset in above mentioned case is secondary to Flumazenil administration in susceptible patient with previous history of ischemic heart disease. Ventricular tachycardia has rarely reported as flumazenil side effects.

Improvement of decerebrate status in a hanged child following emergent tracheostomy.

This study is a clinical description of one child with decerebrated status due to hanging that made excellent recovery. There are limited reports have explained decerebrated status improvement among children in the literature. The case presented, is an eleven year-old boy brought by Emergency Medical Services into the Emergency Department with decerebrated status due to hanging during swinging. Concerning severe hypoxemia and suspected, emergent tracheostomy was carried out to ensure a proper reliable airway. Patient was put under mechanical ventilation and decerebrated status was surprisingly resolved completely during one hour. We believe that reversible cerebral status has been due to brain stem decreased function without any previous or permanent pathologic neurological disorder.