Subclavian line infiltration causing neck compartment syndrome and bradycardic arrest: A case report.

Unrecognized central venous catheter (CVC) infiltration is an uncommon but potentially life-threatening complication. For instance, a malpositioned subclavian line can infuse into the mediastinum, pleural cavity, or interstitial space of the neck. We present the case of a 30-year-old male with gunshot wounds to the right chest, resuscitated with an initially functional left subclavian CVC, which later infiltrated into the neck causing compression of the carotid sinus and consequent bradycardic arrest. Return of spontaneous circulation (ROSC) was achieved following intravenous epinephrine, cardiac massage, and emergency neck exploration and cervical fasciotomy. Our case highlights the importance of frequent reassessment of lines, especially those placed during fast-paced, high-intensity clinical situations. We recommend being mindful when using rapid transfusion devices as an interstitial catheter may not mount enough back pressure to trigger the system's alarm before significant tissue damage or compartment syndrome occurs.

The relationship between perioperative central venous oxygen saturation and postoperative complications in highly invasive gastroenterological surgery.

Purpose: Operations for malignant diseases of the bile duct, pancreas, and esophagus are the most invasive gastroenterological surgeries. The frequency of complications after these surgeries is high, which affects the postoperative course and mortality. In patients who undergo these types of surgeries, continuous monitoring of the perioperative central venous oxygen saturation (ScvO2) is possible via a central venous catheter. We aimed to investigate the relationship between continuously monitored perioperative ScvO2 values and postoperative complications. Methods: The medical records of 115 patients who underwent highly invasive gastroenterological surgeries and ScvO2 monitoring from April 2012 to March 2014 were analyzed. Sixty patients met the inclusion criteria, and their ScvO2 levels were continuously monitored perioperatively. The relationship between ScvO2 levels and major postoperative complications, defined as Clavien-Dindo grade ≥ III, was examined using uni- and multivariate analysis. Results: Thirty patients developed major postoperative complications. The adequate cut-off value derived from receiver operating curves of the postoperative average ScvO2 levels for predicting major complications was 75%. Multivariate analysis revealed that low average postoperative ScvO2 levels (p = 0.016) and blood loss ≥ 1000 mL (p = 0.039) were significant predictors of major postoperative complications. Conclusions: Low perioperative ScvO2 values were associated with an increased risk of major postoperative complications. Continuous ScvO2 monitoring will help prevent postoperative complications.

The use of Guyton's approach to the control of cardiac output for clinical fluid management.

Infusion of fluids is one of the most common medical acts when resuscitating critically ill patients. However, fluids most often are given without consideration of how fluid infusion can actually improve tissue perfusion. Arthur Guyton's analysis of the circulation was based on how cardiac output is determined by the interaction of the factors determining the return of blood to the heart, i.e. venous return, and the factors that determine the output from the heart, i.e. pump function. His theoretical approach can be used to understand what fluids can and cannot do. In his graphical analysis, right atrial pressure (RAP) is at the center of this interaction and thus indicates the status of these two functions. Accordingly, trends in RAP and cardiac output (or a surrogate of cardiac output) can provide important guides for the cause of a hemodynamic deterioration, the potential role of fluids, the limits of their use, and when the fluid is given, the response to therapeutic interventions. Use of the trends in these values provide a physiologically grounded approach to clinical fluid management.

Flow Analysis of Central Venous Outflow Tract: A New Approach to Understanding Pulse-Synchronous Tinnitus.

OBJECTIVE: Pulse-synchronous tinnitus (PST) has been linked to multiple anatomical variants of the central venous outflow tract (CVOT) including sigmoid sinus (SS) dehiscence and diverticulum. This study investigates flow turbulence, pressure, and wall shear stress along the CVOT and proposes a mechanism that results in SS dehiscence and PST. STUDY DESIGN: Case series. SETTING: Tertiary Academic Center. METHODS: Venous models were reconstructed from computed tomography scans of 3 patients with unilateral PST. Two models for each patient are obtained: a symptomatic and contralateral asymptomatic side. A turbulent model-enabled commercial flow solver was used to simulate the pulsatile blood flow over the cardiac cycle through the models. Fluid flow through the transverse and SS junction was analyzed to observe the velocity, pressure, turbulent kinetic energy (TKE), and shear stress over a simulated cardiac cycle. RESULTS: Fluid flow on the symptomatic side showed increased vorticity in the presence of an SS diverticulum. Higher TKE with periodicity following the cardiac cycle was observed on the symptomatic side, and a sharp increase was observed if SS diverticulum was present. Shear stress was highest near the narrowest segments of the vessel. Pressure was observed to be lower on the symptomatic side at the transverse-SS junction for all 3 patients. CONCLUSION: Computational fluid dynamics modeling of blood flow through the CVOT in PST suggests that low pressure may be the cause of dehiscence, and tinnitus may result from periodic increases in TKE.

Evaluating the effects of comprehensive simulation on central venous catheterization training: a comparative observational study.

BACKGROUND: Simulation-based training (SBT) is vital to complex medical procedures such as ultrasound guided central venous catheterization (US-IJCVC), where the experience level of the physician impacts the likelihood of incurring complications. The Dynamic Haptic Robotic Trainer (DHRT) was developed to train residents in CVC as an improvement over manikin trainers, however, the DHRT and manikin trainer both only provide training on one specific portion of CVC, needle insertion. As such, CVC SBT would benefit from more comprehensive training. An extended version of the DHRT was created, the DHRT + , to provide hands-on training and automated feedback on additional steps of CVC. The DHRT + includes a full CVC medical kit, a false vein channel, and a personalized, reactive interface. When used together, the DHRT and DHRT + systems provide comprehensive training on needle insertion and catheter placement for CVC. This study evaluates the impact of the DHRT + on resident self-efficacy and CVC skill gains as compared to training on the DHRT alone. METHODS: Forty-seven medical residents completed training on the DHRT and 59 residents received comprehensive training on the DHRT and the DHRT + . Each resident filled out a central line self-efficacy (CLSE) survey before and after undergoing training on the simulators. After simulation training, each resident did one full CVC on a manikin while being observed by an expert rater and graded on a US-IJCVC checklist. RESULTS: For two items on the US-IJCVC checklist, "verbalizing consent" and "aspirating blood through the catheter", the DHRT + group performed significantly better than the DHRT only group. Both training groups showed significant improvements in self-efficacy from before to after training. However, type of training received was a significant predictor for CLSE items "using the proper equipment in the proper order", and "securing the catheter with suture and applying dressing" with the comprehensive training group that received additional training on the DHRT + showing higher post training self-efficacy. CONCLUSIONS: The integration of comprehensive training into SBT has the potential to improve US-IJCVC education for both learning gains and self-efficacy.

Ultrasound based estimate of central venous pressure: Are we any closer?

Central venous pressure (CVP) serves as a direct approximation of right atrial pressure and is influenced by factors like total blood volume, venous compliance, cardiac output, and orthostasis. Normal CVP falls within 8-12 mmHg but varies with volume status and venous compliance. Monitoring and managing disturbances in CVP are vital in patients with circulatory shock or fluid disturbances. Elevated CVP can lead to fluid accumulation in the interstitial space, impairing venous return and reducing cardiac preload. While pulmonary artery catheterization and central venous catheter obtained measurements are considered to be more accurate, they carry risk of complications and their usage has not shown clinical improvement. Ultrasound-based assessment of the internal jugular vein (IJV) offers real-time, non-invasive measurement of static and dynamic parameters for estimating CVP. IJV parameters, including diameter and ratio, has demonstrated good correlation with CVP. Despite significant advancements in non-invasive CVP measurement, a reliable tool is yet to be found. Present methods can offer reasonable guidance in assessing CVP, provided their limitations are acknowledged.

CO2 gap changes compared with cardiac output changes in response to intravenous volume expansion and/or vasopressor therapy in septic shock.

Background: The difference in partial pressure of carbon dioxide (PCO2) between mixed or central venous blood and arterial blood, known as the ∆PCO2 or CO2 gap, has demonstrated a strong relationship with cardiac index during septic shock resuscitation. Early monitoring of the ∆PCO2 can help assess the cardiac output (CO) adequacy for tissue perfusion. Objectives: To investigate the value of ∆PCO2 changes in early septic shock management compared with CO. Methods: This observational prospective study included 76 patients diagnosed with septic shock admitted to Cairo University Hospital's Critical Care Department between December 2020 and March 2022. Patients were categorised by initial resuscitation response, initial ∆PCO2 and 28-day mortality. The primary outcome was the relationship between the ∆PCO2 and CO changes before and after initial resuscitation, with secondary outcomes including ICU length of stay (LOS) and 28-day mortality. Results: Peri-resuscitation ∆PCO2 changes predicted a ≥15% change in the cardiac index (CI) (area under the curve (AUC) 0.727; 95% CI 0.614 - 0.840) with 66.7% sensitivity and 62.8% specificity. The optimal ∆PCO2 change cut-off value was <-1.85, corresponding to a <-22% threshold for a 15% cardiac index increase. The PCO2 gap ratio (gap/gap ratio of T1- PCO2 gap to T0 -PCO2 gap) also predicted a ≥15% change in cardiac index (AUC 745; 95% CI 0.634 - 0.855) with 63.6% sensitivity and 79.1% specificity. The optimal CO2 gap/gap ratio cut-off value was <0.71. A significant difference in 28-day mortality was noted based on the gap/gap ratio. Conclusion: Peri-resuscitation ∆PCO2 and the gap/gap ratio are useful non-invasive bedside markers for predicting changes in CO and preload responsiveness. Contribution of the study: The current study provides an insight to the PCO2 gap changes during and after early resuscitation of septic shock patients, which correlate to cardiac output changes and might also serve as a fluid responsiveness indicator.

Rare Central Venous Catheter Malpositions: A Case Series.

Central venous catheters are a procedure that provides vascular access, allowing the application of various clinical treatments and the measurement of some hemodynamic values. It provides access to the internal jugular vein, subclavian vein, and, femoral vein with a large-bore catheter. There are mechanical, infectious, and thromboembolic complications resulting from central venous catheter placement and care. Central venous catheter malposition is a rare catheter complication that may be encountered. The location of the central venous catheter can be evaluated with imaging techniques such as posteroanterior chest radiograph, ultrasonography, central venous catheter waveform, and transesophageal echocardiography. Five malposition cases detected by imaging after the central venous catheter procedure in our clinic are presented.

A Systematic Review and Meta-analysis of 24 Month Patency After Endovenous Stenting of Superior Vena Cava, Subclavian, and Brachiocephalic Vein Stenosis.

OBJECTIVE: This systematic review and meta-analysis aimed to appraise recent evidence assessing patency outcomes at various time points in patients with superior vena cava, subclavian, and brachiocephalic vein stenosis who had undergone stenting. DATA SOURCES: PubMed, Scopus, and Cochrane Library databases were searched for studies up to December 2022. REVIEW METHODS: Measured outcomes included technical success rate, primary, primary assisted, and secondary patency at various time points. A subgroup analysis was also conducted to compare malignant and benign obstruction. GRADE was used to assess the certainty of evidence. RESULTS: Thirty nine studies reporting outcomes in 1539 patients were included in the meta-analysis. Primary patency up to 1 year after the procedure was 81.5% (95% CI 74.5 - 86.9%). Primary patency declined after 1 year to 63.2% (95% CI 51.9 - 73.1%) at 12 - 24 months. Primary assisted patency and secondary patency at ≥ 24 months were 72.7% (95% CI 49.1 - 88.0%) and 76.6% (95% CI 51.1 - 91.1%). In the subgroup analysis, primary patency was significantly higher in patients with a malignant stenosis compared with a benign stenosis at 1 - 3 and 12 - 24 months. No significant difference was seen for pooled secondary patency rates when comparing the malignant and benign subgroups. GRADE analysis determined the certainty of evidence for all outcomes to be very low. CONCLUSION: Stenting is an effective intervention for benign and malignant stenosis of the superior vena cava, subclavian, and brachiocephalic veins. Primary patency rates were good up to 1 year after the procedure, with 81.5% of stents retaining patency at 6 - 12 months. Patency rates declined after 1 year, to 63.2% primary and 89.3% secondary patency at 12 - 24 months, showing improved outcomes following re-intervention. High quality evidence is lacking. More research is needed to investigate patency outcomes and the need for surveillance or re-intervention programme.

Indwelling-tunneled-central-venous-catheter-related early bacteremia and preoperative prophylaxis: a case and control study. / Bacteriemia precoz asociada a catéter venoso central tunelizado permanente y profilaxis preoperatoria: estudio de casos y controles.

INTRODUCTION: The indication of preoperative prophylaxis in the insertion of indwelling tunneled central venous catheters (ITCVC) has a low level of evidence. Our objective was to assess risk factors of ITCVC-related early bacteremia in oncological pediatric patients and to determine the need for preoperative prophylaxis. MATERIALS AND METHODS: A univariate and multivariate retrospective analysis of patients in whom an ITCVC was placed from January 2020 to July 2023, according to whether they had ITCVC-related early bacteremia (EB) in the first 30 postoperative days, was carried out. Demographic variables, leukopenia, neutropenia, use of preoperative antibiotic prophylaxis, and history of central venous catheter (CVC) or bacteremia were collected. Calculations were carried out using the IBM SSPS29® software. RESULTS: 176 patients with a mean age of 7.6 years (SD: 4.82) were analyzed. 7 EB cases were identified, with a greater frequency of neutropenia (p= 0.2), history of CVC in the 48 hours before insertion (p= 0.08), and intraoperative CVC (p= 0.04). The presence of intraoperative CVC increased the risk of EB 9-fold [OR: 9.4 (95%CI: 1.288-69.712) (p= 0.027)]. The lack of preoperative prophylaxis did not increase the risk of EB [OR: 2.2 (CI: 0.383-12.669) (p= 0.3)]. The association with other variables was not significant. CONCLUSIONS: The intraoperative presence of CVC was a risk factor of EB in our patients. Preoperative prophylaxis had no impact on the risk of EB, which in our view does not support its use. However, further studies with a larger sample size are required. Leukopenia or neutropenia at diagnosis were not associated with a greater prevalence of infection.

INTRODUCCION: La indicación de profilaxis preoperatoria en la colocación de catéteres venosos centrales tunelizados permanentes (CVCTP) tiene bajo nivel de evidencia. Nuestro objetivo fue evaluar factores de riesgo de bacteriemia precoz asociada a CVCTP en pacientes pediátricos oncológicos y determinar la necesidad de profilaxis preoperatoria. MATERIAL Y METODOS: Realizamos un análisis retrospectivo univariante y multivariante de los pacientes con colocación de CVCTP entre enero 2020 y julio 2023, en función de si presentaron bacteriemia precoz (BP) relacionada con CVCTP en los primeros 30 días postoperatorios. Recogimos variables demográficas y otras como: leucopenia, neutropenia, uso de profilaxis antibiótica preoperatoria y antecedente de catéter venoso central (CVC) o bacteriemia. Los cálculos se realizaron mediante el software IBM SSPS29®. RESULTADOS: Analizamos 176 pacientes, con edad media de 7,6 años (SD 4,82). Identificamos 7 casos de BP, que presentaron mayor frecuencia de neutropenia (p=  0,2) y antecedente de CVC las 48h previas a la colocación (p=  0,08) y CVC intraoperatorio (p=  0,04). La presencia de CVC intraoperatorio aumentó 9 veces el riesgo de BP [OR 9,4 (IC 95% de 1,288-69,712) (p=  0,027)]. La falta de profilaxis prequirúrgica no aumentó el riesgo de BP [OR 2,2 (IC 0,383-12,669) (p=  0,3)]. La relación con otras variables no fue significativa. CONCLUSIONES: La presencia intraoperatoria de CVC fue factor de riesgo de BP en nuestros pacientes. La profilaxis preoperatoria no influyó sobre el riesgo de BP, por lo que creemos que su empleo no está justificado, aunque se necesitarían más estudios con mayor tamaño muestral. La leucopenia o neutropenia al momento diagnóstico no se relacionaron con mayor prevalencia de infección.

An ultrasound-guided supraclavicular approach for tunneled central venous catheter insertion can be safely performed by junior residents.

PURPOSE: Ultrasound-guided supraclavicular catheterization (UGSC) of the brachiocephalic vein (BCV) for long-term tunneled central venous catheter (tCVC) insertion may be safer than the internal jugular vein approach due to its superior field of view. We examined the clinical outcomes of tCVC insertions performed by junior residents through UGSC of the BCV. PATIENTS AND METHODS: From January 2018 to December 2023, we assessed clinical outcomes and compared the experience levels of surgeons conducting tCVC insertions. Surgeons were categorized into three groups: junior residency (JR), senior residency (SR), and board-certified pediatric surgeons (BCPS). RESULTS: 177 tCVC insertions were done on 146 patients. Intraoperative complications included 6 cases of arterial puncture, 1 case of pneumothorax, 1 case of over insertion of catheter tip, and 1 case of suspected hemothorax. Distribution across groups was as follows: 28 cases (15.8%) in JR group, 92 (52.0%) in SR group, and 57 (32.2%) in BCPS group. Although the JR group exhibited longer operation times than the BCPS group, no significant differences in intraoperative complications were noted. CONCLUSION: Junior residents can safely perform UGSC for tCVC insertion. However, careful consideration of complications such as arterial or thoracic puncture is essential and case selection should be based on experience.

Association between early central venous pressure measurement and all-cause mortality in critically ill patients with heart failure: A cohort of 11,241 patients.

Background: The timing of central venous pressure (CVP) measurement may play a crucial role in heart failure management, yet no studies have explored this aspect. Methods: Clinical information pertaining to patients in critical condition with a diagnosis of heart failure was retrieved from the MIMIC-IV database. The association between initial measurements of central venous pressure (CVP) and the incidence of mortality from all causes was analyzed using the Cox proportional hazards approach. Subgroup analysis and propensity score matching were conducted for sensitivity analyses. Results: This study included 11,241 participants (median age, 75 years; 44.70 % female). Utilizing restricted cubic spline and Kaplan-Meier survival analyses, it was determined that prognostic outcomes were better when CVP was measured within the initial 5-h window. Multivariate-adjusted 1-year (HR: 0.69; 95 % CI: 0.61-0.77), 90-day (HR: 0.70; 95 % CI: 0.62-0.80), and 30-day (HR: 0.67; 95 % CI: 0.57-0.78) all-cause mortalities were significantly lower in patients with early CVP measurement, which was proved robustly in subgroup analysis. Subsequent to the application of propensity score matching, a cohort of 1536 matched pairs was established, with the observed mortality rates continuing to be significantly lower among participants who underwent early CVP assessment. Conclusions: Early CVP measurement (within 5 h) demonstrated an independent correlation with a decrease in both immediate and extended all-cause mortality rates among patients in critical condition suffering from heart failure.

Central venous pressure waveform analysis during sleep/rest: a novel approach to enhance intensive care unit post-extubation monitoring of extubation failure.

This pilot study aimed to investigate the relation between cardio-respiratory parameters derived from Central Venous Pressure (CVP) waveform and Extubation Failure (EF) in mechanically ventilated ICU patients during post-extubation period. This study also proposes a new methodology for analysing these parameters during rest/sleep periods to try to improve the identification of EF. We conducted a prospective observational study, computing CVP-derived parameters including breathing effort, spectral analyses, and entropy in twenty critically ill patients post-extubation. The Dynamic Warping Index (DWi) was calculated from the respiratory component extracted from the CVP signal to identify rest/sleep states. The obtained parameters from EF patients and patients without EF were compared both during arbitrary periods and during reduced DWi (rest/sleep). We have analysed data from twenty patients of which nine experienced EF. Our findings may suggest significantly increased respiratory effort in EF patients compared to those successfully extubated. Our study also suggests the occurrence of significant change in the frequency dispersion of the cardiac signal component. We also identified a possible improvement in the differentiation between the two groups of patients when assessed during rest/sleep states. Although with caveats regarding the sample size, the results of this pilot study may suggest that CVP-derived cardio-respiratory parameters are valuable for monitoring respiratory failure during post-extubation, which could aid in managing non-invasive interventions and possibly reduce the incidence of EF. Our findings also indicate the possible importance of considering sleep/rest state when assessing cardio-respiratory parameters, which could enhance respiratory failure detection/monitoring.

Central Venous Catheter Misplacement Into Pleural Cavity Causing Hypertensive Pleural Effusion: A Case Report.

Central venous catheter (CVC) insertion is a routine procedure in the management of critically ill patients. We report a clinical case of inadvertent placement of an internal jugular vein CVC into the right pleural cavity, despite employing clinical and imaging-based techniques to ensure proper catheter positioning. Infusion of fluids and vasopressors through this misplaced catheter led to hypertensive pleural effusion and subsequent cardiorespiratory arrest. Return of spontaneous circulation was achieved after two cycles of cardiopulmonary resuscitation. While multiple imaging modalities are recommended for confirming appropriate CVC placement, each method has inherent limitations. This case highlights the imperative need for a high index of suspicion to avert such complications and pretends to review some of each method's limitations.

Nurses' evidence-based knowledge and self-efficacy in venous access device insertion and management: Development and validation of a questionnaire.

AIM: To develop and psychometrically test an instrument to assess nurses' evidence-based knowledge and self-efficacy regarding insertion and management of venous access devices (short peripheral catheter (SPC), long peripheral catheter/midline (LPC) and PICC) and the management of totally implantable central venous catheter (Port) in adult patients. DESIGN: Multicenter cross-sectional observational study with questionnaire development and psychometric testing (validity and reliability). METHODS: An evidence-based instrument was developed including a 34-item knowledge section and an 81-item self-efficacy section including four device-specific parts. Nineteen experts evaluated content validity. A pilot study was conducted with 86 nurses. Difficulty and discrimination indices were calculated for knowledge items. Confirmatory factor analyses tested the dimensionality of the self-efficacy section according to the development model. Construct validity was tested through known group validity. Reliability was evaluated through Cronbach's alpha coefficient for unidimensional scales and omega coefficients for multidimensional scales. RESULTS: Content validity indices and results from the pilot study were excellent with all the item-content validity indices >0.78 and scale-content validity index ranging from 0.96 to 0.99. The survey was completed by 425 nurses. Difficulty and discrimination indices for knowledge items were acceptable with most items (58.8%) showing desirable difficulty and most items (58.8%) with excellent (35.3%) or good (23.5%) discrimination power, and appropriate to the content. The dimensionality of the model posited for self-efficacy was confirmed with adequate fit indices (e.g., comparative fit index range 0.984-0.996, root mean square error of approximation range 0.054-0.073). Construct validity was determined and reliability was excellent with alpha values ranging from 0.843 to 0.946 and omega coefficients ranging from 0.833 to 0.933. Therefore, a valid and reliable tool based on updated guidelines is made available to evaluate nurses' competencies for venous access insertion and management.

Current surgical practice for central venous access to deliver chemotherapy and enteral access for nutritional support in pediatric patients with an oncological diagnosis.

Central venous access through tunneled central venous catheters (CVCs) are one of the cornerstones of modern oncologic practice in pediatric patients since CVCs provide a reliable access route for the administration of chemotherapy. Establishing best practices for CVC management in children with cancer is essential to optimize care. This article reviews current best practices, including types of devices, their placement, complications, and long-term outcomes. Additionally, nutrition status and nutritional support are also very important determinants of outcomes and care in pediatric surgical oncology patients. We review current nutritional assessment, support, access for enteral and parenteral nutrition delivery, and their complications, mainly from a surgical perspective. Overall, access surgery, whether for CVCs, or for enteral access can be challenging, and best practice guidelines supported by current though limited evidence are necessary to minimize complications and optimize outcomes.

Can central venous pressure help identify acute right ventricular dysfunction in mechanically ventilated critically ill patients?

OBJECTIVE: To investigate the relationship between central venous pressure (CVP) and acute right ventricular (RV) dysfunction in critically ill patients on mechanical ventilation. METHODS: This retrospective study enrolled mechanically ventilated critically ill who underwent transthoracic echocardiographic examination and CVP monitoring. Echocardiographic indices including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tricuspid lateral annular systolic velocity wave (S') were collected to assess RV function. Patients were then classified into three groups based on their RV function and presence of systemic venous congestion as assessed by inferior vena cava diameter (IVCD) and hepatic vein (HV) Doppler: normal RV function (TAPSE ≥ 17 mm, FAC ≥ 35% and S' ≥9.5 cm/sec), isolated RV dysfunction (TAPSE < 17 mm or FAC < 35% or S' <9.5 cm/sec with IVCD ≤ 20 mm or HV S ≥ D), and RV dysfunction with congestion (TAPSE < 17 mm or FAC < 35% or S' <9.5 cm/sec with IVCD > 20 mm and HV S < D). RESULTS: A total of 518 patients were enrolled in the study, of whom 301 were categorized in normal RV function group, 164 in isolated RV dysfunction group and 53 in RV dysfunction with congestion group. Receiver operating characteristic analysis revealed a good discriminative ability of CVP for identifying patients with RV dysfunction and congestion(AUC 0.839; 95% CI: 0.795-0.883; p < 0.001). The optimal CVP cutoff was 10 mm Hg, with sensitivity of 79.2%, specificity of 69.4%, negative predictive value of 96.7%, and positive predictive value of 22.8%. A large gray zone existed between 9 mm Hg and 12 mm Hg, encompassing 95 patients (18.3%). For identifying all patients with RV dysfunction, CVP demonstrated a lower discriminative ability (AUC 0.616; 95% CI: 0.567-0.665; p < 0.001). Additionally, the gray zone was even larger, ranging from 5 mm Hg to 12 mm Hg, and included 349 patients (67.4%). CONCLUSIONS: CVP may be a helpful indicator of acute RV dysfunction patients with systemic venous congestion in mechanically ventilated critically ill, but its accuracy is limited. A CVP less than10 mm Hg can almost rule out RV dysfunction with congestion. In contrast, CVP should not be used to identify general RV dysfunction.

Quality of life in women with breast cancer undergoing neoadjuvant chemotherapy: comparison between PICC and PICC-port.

BACKGROUND: Peripherally inserted central catheters (PICCs) and new type of arm-port, the PICC-port, are currently used for neoadjuvant chemotherapy treatment in patients with breast cancer. We aimed to compare Quality of Life (QoL) of patients receiving one of these two devices investigating overall satisfaction, psychological impact, as well as the impact on professional, social and sport activities, and local discomfort. METHODS: We did a prospective observational before-after study of PICCs versus PICC-ports. Adult (aged ≥ 18 years) females with breast cancer candidate to neoadjuvant chemotherapy were included. The primary outcome was QoL according to the Quality-of-Life Assessment Venous Device Catheters (QLAVD) questionnaire assessed 12 months after device implantation. RESULTS: Between May 2019 and November 2020, of 278 individuals screened for eligibility, 210 were enrolled. PICC-ports were preferred over PICCs with a QLAVD score of 29 [25; 32] vs 31 [26; 36.5] (p = 0.014). Specifically, most QLAVD constructs related to psychological impact, social aspects, and discomfort were in favor of PICC-ports vs PICC, especially in women under the age of 60. Overall, pain scores at insertion and during therapy administration were not significantly different between the two groups, as well as infection, secondary malpositioning, thrombosis, or obstruction of the device. CONCLUSIONS: In women with breast cancer undergoing neoadjuvant chemotherapy, PICC-ports were overall better accepted than PICCs in terms of QoL, especially in those who were younger. Device-related complications were similar.