Ultrasound-guided radial artery catheterisation increases the success rate among anaesthesiology residents: a randomised study.

INTRODUCTION: The palpation technique is generally used for radial artery catheterisation, but is associated with a high rate of failure and complications. Dynamic needle tip positioning (DNTP) is a new ultrasound-guided technique. We aimed to compare the traditional palpation technique with DNTP performed by four anaesthesiology residents. METHODS: The study was a randomised, controlled, patient-blinded, crossover study. Fourty patients underwent bilateral radial artery catheterisation using both techniques. The primary endpoint was the first attempt success rate. The secondary endpoints were: 1) number of skin perforations, 2) number of needle retractions, 3) needle manipulation time, 4) total time, 5) attempts lasting >180 seconds, 6) number of catheters used, 7) frequency of aborted attempts or crossovers, and 8) pain scores (VAS). RESULTS: The first attempt success rate was significantly higher in the DNTP group compared with the palpation group (36/40 vs. 28/40, p = 0.022).The palpation technique group required a higher number of skin perforations (44 vs. 60, p = 0.016), needle retractions (p = 0.001) and catheters (42 vs. 52, p = 0.011) compared with the DNTP group. Neither the total time required for arterial catheterisation, the needle manipulation time nor the VAS scores were significantly different between the groups (all p>0.407). Aborted attempts were only seen in the palpation group (7/40, p = 0.016). CONCLUSIONS: Ultrasound-guided arterial catheterisation using the DNTP technique is superior to the standard palpation technique. This study favours the ultrasound-guided DNTP technique as the first choice rather than merely being viewed as a rescue procedure.

[Wandering spleen in a patient hospitalized with acute abdomen].

An 11-year-old girl was hospitalized with a two-day history of lower abdominal pain. The patient had a localized peritoneal reaction in the right lower quadrant, an elevated C-reactive protein level, and an increased white blood cell count. On the suspicion of acute appendicitis a diagnostic laparoscopy was performed. This revealed a misplaced spleen in the right side of the pelvis with a partly torsion of a long vascular pedicle. The splenic tissue was vital without any sign of ischaemia. However, splenopexy was not possible, and an uncomplicated elective splenectomy was performed.

Guidance markers increase the accuracy of simulated ultrasound-guided vascular access: an observational cohort study in a phantom.

INTRODUCTION: Peripheral ultrasound (US)-guided vascular access is gaining popularity. Though studies have demonstrated that US-guided vascular access has several advantages, the procedure is challenging to even the most experienced operator. The aim of this observational cohort study was to investigate whether adding guidance markers on a US system would increase the accuracy of US-guided needle tip placement compared to no guidance markers. METHODS: A total of 18 physicians and 12 nurses familiar with US-guided vascular access volunteered to participate. Two identical US systems were used. System A was as manufactured. System B included three guide markers drawn on the transducer and screen. The participants performed six needle insertions in a gelatin phantom with three imbedded targets. First participants used US system A and then US system B. Primary endpoint was horizontal distance between needle tip and target. Secondary endpoint was participant's subjective feeling of advantage of the guidance markers measured on a Likert scale. RESULTS: Guidance markers on the US system significantly increased the accuracy of needle placement on all three targets individually (p = 0.00) and on overall placement, (inter-quartile range 3.21 mm vs. 0.49 mm, p = 0.00). In addition, the use of guidance markers eliminated the difference in accuracy between physicians and nurses, respectively. All participants evaluated the guidance markers to be helpful during the needle insertions. CONCLUSIONS: Adding guidance markers to the US system significantly increased the accuracy of needle placement in the horizontal plane during simulated US-guided vascular access using a phantom.

[Toothpick perforation in the ventricle].

A 60-year-old male was admitted with acute abdominal pain and fever. Computed tomography (CT) of the abdomen revealed free air. Diagnostic laparoscopy showed a toothpick perforating the ventricle, and the toothpick was removed successfully. This condition is severe with a reported mortality of 9.6%. A practical guideline based on 136 cases was presented in 2014. Endoscopy was found to be superior to CT in identifying toothpicks as well as offering therapeutic intervention, rendering endoscopy the first choice in diagnostic and treatment. Subsequently CT or ultrasound is recommended in the unresolved patient.

Complete genome sequence of the cystic fibrosis pathogen Achromobacter xylosoxidans NH44784-1996 complies with important pathogenic phenotypes.

Achromobacter xylosoxidans is an environmental opportunistic pathogen, which infects an increasing number of immunocompromised patients. In this study we combined genomic analysis of a clinical isolated A. xylosoxidans strain with phenotypic investigations of its important pathogenic features. We present a complete assembly of the genome of A. xylosoxidans NH44784-1996, an isolate from a cystic fibrosis patient obtained in 1996. The genome of A. xylosoxidans NH44784-1996 contains approximately 7 million base pairs with 6390 potential protein-coding sequences. We identified several features that render it an opportunistic human pathogen, We found genes involved in anaerobic growth and the pgaABCD operon encoding the biofilm adhesin poly-ß-1,6-N-acetyl-D-glucosamin. Furthermore, the genome contains a range of antibiotic resistance genes coding efflux pump systems and antibiotic modifying enzymes. In vitro studies of A. xylosoxidans NH44784-1996 confirmed the genomic evidence for its ability to form biofilms, anaerobic growth via denitrification, and resistance to a broad range of antibiotics. Our investigation enables further studies of the functionality of important identified genes contributing to the pathogenicity of A. xylosoxidans and thereby improves our understanding and ability to treat this emerging pathogen.