Blind placements of peripherally inserted antecubital central catheters: initial catheter tip position in relation to carina.

BACKGROUND: We investigated how often blind placement of peripherally inserted central catheters (PICCs) through the antecubital veins results in a correct tip location in relation to carina and evaluated the inter-observer agreement in locating the tip of PICCs in plain radiography with digital imaging. METHODS: In this study, 202 suitable chest radiographs with PICCs out of 803 patients were identified. An initial audit on the tip of these catheters in relation to carina was done by a consultant anaesthetist and was recorded as the first observer. The same sets of CXRs were examined by a consultant radiologist and the tips were identified and recorded as the second observer. Inter-observer agreement was assessed. RESULTS: In 75 of 202 (37%), PICCs had a central tip location in relation to the carina. Fifty-five of 131 (42%) right-sided catheters had a central location compared with 20 of 71 (28%) of the left-sided catheters. The tip position for right-sided catheters was most frequently centrally located whereas the tip for left-sided catheters was most commonly positioned in the ipsilateral innominate vein. There was excellent agreement between the observers in reporting the tip of PICCs at all positions (kappa=0.87) including central locations (kappa=0.83). CONCLUSIONS: Right antecubital PICCs are more likely to be placed in the central location in relation to the carina. PICCs inserted through the left antecubital veins need to be pushed further down to aim for a central location. Inter-observer variability in identifying the tip of PICCs is least with the introduction of digital imaging.

Inhibition of wound contraction by point-to-point adherent splintage.

The contractile force generated by the healing wound can be visualized as the sum of the forces of contraction developed across each of the minute segments of the scar. If splintage is effected in such a way that the splint itself adheres to the scar, each small segment of the splint needs to be rigid enough to resist only the minute contractile force generated by the corresponding small segment of the scar. This hypothesis was tested by means of an experiment using 30 adult white rats. Two full-thickness wounds were created on the backs of each animal and covered with split-thickness skin grafts. One of the grafted areas was splinted by an adherent acrylic membrane and the other was left unsplinted, acting as the control. At 8 weeks, the splinted grafts had retained 95 percent of the original size. The difference between the splinted and unsplinted grafts was statistically significant. Further evaluation of the principle of adherent nonrigid splintage could lead to its application in the clinical context.

Temporomandibular arthroplasty by pedicled transfer of the sternoclavicular joint--a simplified technique.

One of the options available for the treatment of temporomandibular ankylosis is the replacement of the joint by the sternoclavicular joint pedicled on neck muscles. This paper describes a modified technique of pedicled sternoclavicular joint transfer and evaluates its advantages.

Pneumatization of the paranasal sinuses (maxillary and frontal) in cleft lip and palate.

A comparative study of roentgenograms of the paranasal sinuses between 37 patients with cleft lip and palate and 37 control subjects of the same age group was done using a planimeter. The results indicate that there is no statistical difference in the sizes. The paranasal sinuses increased in size with age in patients as well as in control subjects.

A modified needle holder for microsurgery.

Skillful handling of a microsurgical needle holder is dependent not only on manual dexterity but also on the ergonomics of its design. This paper presents the design of a modified needle holder that makes it better suited to the atraumatic passage of a semi-circular needle through tissues.

Vascularized innervated transfer of the clavicular head of the pectoralis major muscle in established facial paralysis.

Twenty cadaver dissections of the clavicular head of the pectoralis major muscle were carried out to determine the detailed anatomical arrangement of the vascular and nerve supply, with a view to using this muscle as an independent neuromyovascular unit in the treatment of established facial palsy. In all dissections, the muscle was found to have an independent nerve and vascular supply. A clinical case is reported with anatomical description and essential details of the operative technique. The ideal neuromyovascular unit is briefly described and the advantages of the pectoralis major for this use are illustrated. It is emphasized that limiting the goals of free muscle transfer to reanimation of the lower facial musculature will produce the most satisfactory results.