Erroneous placement of central venous catheter in the subclavian artery: retrieval and successful hemostasis with a femoral closure device.

Central venous catheter (CVC) placement, even if performed under duplex scan control, may be associated with incidental arterial injury leading to increased morbidity, mortality, and prolonged hospital stay. Erroneous CVC placement in the carotid or subclavian arteries has been usually treated surgically because those puncture sites may not be efficaciously compressed manually. However, surgery in this setting may be challenging because of difficulty of access for the catheters positioned in the subclavian artery and of the risk of cerebrovascular complications for carotid catheters. Recently, several cases have been published, describing the successful endovascular management of iatrogenic arterial injury using different types of vascular closure devices (VCD). However, in this setting, it remains difficult to be completely sure that the VCD has achieved complete hemostasis and that the patient does not subsequently incur in a clinically silent intrathoracic bleeding. We report the case of an erroneous CVC placement in the right subclavian artery successfully retrieved using an Angioseal VCD. The immediate and complete hemostasis at the puncture site was confirmed at angiography.

Role of intracranial pressure values and patterns in predicting outcome in traumatic brain injury: a systematic review.

INTRODUCTION: Raised intracranial pressure (ICP) has been consistently associated with poor neurological outcome. Our purpose was to systematically review the literature to estimate the association between ICP values and patterns and short- and long-term vital and neurological outcome. METHODS: Systematic review of studies identified from MEDLINE, EMBASE, and COCHRANE Registry search from 1966 to 2005, and reference lists of identified articles, with independent assessment of methodological quality, population, ICP values and patterns, management of raised ICP and neurological outcomes. Summary odds ratios (OR) were calculated for the main outcomes using proportional odds models and logistic regression. RESULTS: Four prospective studies (409 patients) reported the effect of ICP values, and five studies (677 patients) reported the effect of ICP patterns on neurological outcome. No study reported neurological outcomes beyond 1 year. Relative to normal ICP (<20 mmHg), raised ICP was associated with elevated OR of death: 3.5 [95%CI: 1.7, 7.3] for ICP 20-40, and 6.9 [95%CI: 3.9, 12.4] for ICP>40. Raised but reducible ICP was associated with a 3-4-fold increase in the OR of death or poor neurological outcome. Refractory ICP pattern was associated with a dramatic increase in the relative risk of death (OR 114.3 [95%CI: 40.5, 322.3]). CONCLUSIONS: Refractory ICP and response to treatment of raised ICP could be better predictors of neurological outcome than absolute ICP values. Limitations in the design of the studies analyzed precluded identification of the role of ICP monitoring in predicting short- and long-term outcomes.

Continuous cardiac output monitoring after cardiopulmonary bypass: a comparison with bolus thermodilution measurement.

OBJECTIVE: The interchangeability of continuous measurement of cardiac output (CO) with the traditional bolus method in patients after cardiopulmonary bypass (CPB) is uncertain. DESIGN: Prospective observational clinical study. SETTING: A 20-bed surgical ICU at a university hospital. PATIENTS: Fourteen deeply sedated, ventilated, post-cardiac surgery patients, all equipped with a pulmonary artery catheter. INTERVENTIONS: Six hours after the end of the CPB, 56 simultaneous bolus and continuous measurements were compared by a linear regression analysis and Bland-Altman analysis. Bolus CO was estimated by averaging triplicate injections of 10 ml room-temperature NaCl 0.9%, delivered randomly during the respiratory cycle. A stringent maximum difference of 0.55 l min(-1) (about 10% of the mean bolus measured) was considered as a clinically acceptable agreement between the two types of measurements. To be interchangeable the limits of agreement (+/-2 SD of the mean difference between the two methods) should not exceed the chosen acceptable difference. MEASUREMENTS AND RESULTS: Continuous was correlated with bolus CO, with a correlation coefficient of r(2)=0.68. (p<0.01). The Bland-Altman analysis demonstrated an objective mean bias of 0.33+/-0.6 l min(-1) (confidence interval of -0.87-1.58) with 34% of measured values falling outside of the clinically acceptable limits. CONCLUSION: Our results suggest that, in the first 6 h after CPB, continuous and bolus CO determinations are not interchangeable; one third of the values obtained by continuous CO fell outside the strict limits of clinically useful precision.

Transcutaneous PCO2 monitoring in critically ill adults: clinical evaluation of a new sensor.

OBJECTIVE: In critically ill patients, arterial blood gas analysis is the gold standard for evaluating systemic oxygenation and carbon dioxide partial pressure. A new miniaturized carbon dioxide tension Pco2-Spo2 single sensor (TOSCA, Linde Medical Sensors AG, Basel, Switzerland) continuously and noninvasively (transcutaneously) monitors both Paco2 and oxygen saturation by pulse oximetry (Spo2). The present study was designed to investigate the usability and the accuracy of this device in critically ill patients. DESIGN: Prospective clinical investigation. SETTING: A 20-bed, university-affiliated, surgical intensive care unit. PATIENTS: Patients admitted after major surgery, multiple trauma, or septic shock equipped with an arterial catheter. INTERVENTIONS: The heated (42 degrees C) sensor was fixed at the earlobe using an attachment clip. Transcutaneous Pco2 (TcPco2) measurements were correlated with Paco2 values (measured using a blood gas analyzer). In addition, the differences between Paco2 and TcPco2 values were evaluated using the method of Bland-Altman. MEASUREMENTS AND MAIN RESULTS: We studied 55 patients, aged 18-80 (mean 57 +/- 15) yrs. A total of 417 paired measurements were compared. Correlation between TcPco2 and Paco2 was r = .86 (p < .01) in the Paco2 range of 24-101 mm Hg. Mean bias (+/-sd) between the two methods of measurement (Bland-Altman analysis) was 1.2 +/- 6.0 mm Hg with TcPco2 slightly overestimating arterial carbon dioxide tension. Nineteen percent of the measured values were outside of the acceptable clinical range of agreement of +/-7.5 mm Hg. CONCLUSIONS: The present study suggests that Paco2 can be acceptably assessed by measuring TcPco2 using the TOSCA Pco2-Spo2 sensor.

Does continuous positive airway pressure by face mask improve patients with acute cardiogenic pulmonary edema due to left ventricular diastolic dysfunction?

OBJECTIVE: Continuous positive airway pressure (CPAP) by face mask is an effective method of treating severe cardiogenic pulmonary edema (CPE). However, to our knowledge, no study has provided a precise evaluation of the effects of CPAP on cardiac function in patients presenting with CPE and preserved left ventricular (LV) function. DESIGN: Prospective observational clinical study. SETTING: A 14-bed, medical ICU at a university hospital. PATIENTS: Nine consecutive patients presenting with hypoxemic acute CPE. INTERVENTIONS: All patients were selected for 30 min of CPAP with 10 cm H(2)O by mask with fraction of inspired oxygen adjusted for a cutaneous saturation > 90%. Doppler echocardiography was performed before CPAP application and during the last 10 min of breathing with CPAP. Two-tailed, paired t-tests were used to compare data recorded at baseline (oxygen alone) and after CPAP. MEASUREMENTS AND RESULTS: Four patients presented CPE with preserved left ventricular (LV) function (a preserved LV ejection fraction [LVEF] > 45%, and/or aortic velocity time integral > 17 cm in the absence of aortic stenosis or hypertrophic cardiomyopathy). Oxygenation and ventilatory parameters were improved by CPAP in all patients. Hemodynamic monitoring and Doppler echocardiographic analysis demonstrated that in patients with preserved LV systolic function, mean arterial pressure and LV end-diastolic volume were decreased significantly by CPAP (p < 0.04). In patients with LV systolic dysfunction, CPAP improved LVEF (p < 0.05) and decreased LV end-diastolic volume (p = 0.001) significantly. CONCLUSION: CPAP improves oxygenation and ventilatory parameters in all kinds of CPE. In patients with preserved LV contractility, the hemodynamic benefit of CPAP results from a decrease in LV end-diastolic volume (preload).

[Continuous Svo2 measurements and co-oximetry are not interchangeable immediately after cardiopulmonary bypass]. / Après circulation extra-corporelle, la mesure continue de la Svo2 et la co-oxymétrie du sang mêlé ne sont pas interchangeables.

OBJECTIVE: To determine the accuracy of continuous (in vivo) measurement of mixed venous oxygen saturation (SvO(2)), using a fibreoptic catheter, in patients having had cardiopulmonary bypass (CPB). METHODS: Using a pulmonary arterial catheter, we prospectively studied 14 patients (age 64 +/- 8) having had cardiopulmonary bypass. Mean hematocrit was 30 +/- 4%. The catheter was calibrated in vitro and in vivo, according to the manufacturer's instructions. Fifty-six simultaneous measurements of continuous SvO(2) (CSvO(2)) and measured SvO(2) (MSvO(2)) were taken with a co-oxymeter and the paired values were analyzed by the linear regression method. To make the two sets of measurements interchangeable, we established, a priori, a maximum limit of 3% (approximately 5% of the measurement), as being an acceptable difference between the two types of measurements. RESULTS: All the measurements were obtained within four hours of the placement of the catheter. CSvO(2) was weakly correlated with MSvO(2), with a correlation coefficient of r(2) = 0.49 (P < 0.001). The Bland-Altman analysis demonstrates an objective mean bias of 0.8 +/- 3%, with 36% of the values measured falling outside clinically acceptable limits. For values of CSvO(2)