Use of a Guide-wire as an Adjunct for the Safe Removal of a 'Stuck' Indwelling Central Venous Catheter at Risk for Breaking.

Port-based central venous catheters may remain indwelling for years with subsequent fibrosis resulting in a "stuck" catheter. At time of removal, this can lead to complications such as catheter fracture or require additional operative techniques for safe extraction. We present a case utilizing a protocol wherein a J-tip guidewire is placed to assist in removal. We believe this serves the following beneficial functions: Mechanically, as the catheter stretches and collapses upon retraction it distributes the force circumferentially along the length of the catheter as well as reduces angular kinking, mitigating stress points of fracture. Second, in case of fracture, the distal portion should remain intubated by the J-tip guidewire, reducing embolic potential. Third, it allows more facile percutaneous transvenous retrieval if indicated. Though this does not represent a perfect solution to the "stuck" catheter problem, this technique increases safety and efficacy of removal with easy application at minimal additional cost.

Incidental Preduodenal Portal Vein Causing Partial Duodenal Obstruction and Hypertrophied Pre-Pyloric Gastric Polyp.

Preduodenal portal vein (PDPV) is a rare congenital anomaly in which the portal vein lies anterior to the duodenum rather than its normal posterior position. It is a known rare cause of duodenal obstruction and can be associated with other anomalies such as malrotation with or without jejunal atresia. Presented is an incidentally found PDPV causing partial duodenal obstruction during exploration for the resection of a gastric mass and placement of open gastrostomy tube for feeding. This was managed with duodenoduodenostomy, re-creating normal anatomy with portal.

Small Bowel Intussusception Secondary to Malignant Melanoma 11 Years After Melanoma-In-Situ Excision.

Small bowel is a well-described site of malignant melanoma; however, it is a rare cause of intussusception. A patient presented with malignant melanoma causing jejunojejunal intussusception 11 years after resection of melanoma-in-situ. The patient was managed with exploration and resection. Despite complete resection of melanoma-in-situ and limited literature about its metastatic potential, malignant melanoma as a lead point for intussusception should be on the differential for any patient with pertinent history. To our knowledge, this appears to be the first case of melanoma-in-situ causing small bowel intussusception.

Early pneumonia diagnosis decreases ventilator-associated pneumonia rates in trauma population.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a source of morbidity and mortality for trauma patients. Aspiration events are also common because of traumatic brain injury, altered mental status, or facial trauma. In patients requiring mechanical ventilation, early pneumonias (EPs) may be erroneously classified as ventilator associated. METHODS: A prospective early bronchoscopy protocol was implemented from January 2020 to January 2022. Trauma patients intubated before arrival or within 48 hours of admission underwent bronchoalveolar lavage (BAL) within 24 hours of intubation. Patients with more than 100,000 colony-forming units on BAL were considered to have EP. RESULTS: A total of 117 patients underwent early BAL. Ninety-three (79.5%) had some growth on BAL with 36 (30.8%) meeting criteria for EP. For the total study population, 29 patients (24.8%) were diagnosed with VAP later in their hospital course, 12 of which had previously been diagnosed with EP. Of EP patients (n = 36), 21 (58.3%) were treated with antibiotics based on clinical signs of infection. Of EP patients who had a later pneumonia diagnosed by BAL (n = 12), seven (58.3%) grew the same organism from their initial BAL. When these patients were excluded from VAP calculation, the rate was reduced by 27.6%. Patients with EP had a higher rate of smoking history (41.7% vs. 19.8%, p < 0.001) compared with patients without EP. There was no difference in median hospital length of stay, intensive care unit length of stay, ventilator days, or mortality between the two cohorts. CONCLUSION: Early pneumonia is common in trauma patients intubated within the first 48 hours of admission and screening with early BAL identifies patients with aspiration or pretraumatic indicators of pneumonia. Accounting for these patients with early BAL significantly reduces reported VAP rates. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.