Research Progress of Assessment Tools for Peripheral Venous Access Difficulties in Children

Objective:To review the research progress of peripheral venous access difficulty assessment tools in children and to provide a reference for clinical nurses to select and develop appropriate assessment tools.Methods:Search the literature at home and abroad and summarize and analyze the existing evaluation tools.Results:There is no unified assessment tool about difficult venous access in children at home and abroad.The existing tools include the difficult venous access assessment scale and peripheral venous grading assessment tool.Conclusion:The current assessment tools for venous access difficulties in children have their own limitations,and it is necessary to develop further the assessment tools suitable for the cultural background of children's venous access difficulties.This paper summarized the current progress of research on peripheral venous access difficulty assessment tools.It also analyzed and summarized the shortcomings of existing tools to provide a reference for clinical staff to choose appropriate assessment tools.

Endoscopic management of difficult common bile duct stones

Endoscopy is widely accepted as the first treatment option in the management of bile duct stones.In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones.Most biliary stones can be removed with an extraction balloon,extraction basket or mechanical lithotripsy after endoscopic sphincterotomy.Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients.Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed.Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.

Predictors for difficult cecal insertion in colonoscopy: The impact of obesity indices

AIM To identify the factors influencing cecal insertion time(CIT) and to evaluate the effect of obesity indices on CIT. METHODS We retrospectively reviewed the data for participants who received both colonoscopy and abdominal computed tomography(CT) from February 2008 to May 2008 as part of a comprehensive health screening program. Age, gender, obesity indices [body mass index(BMI), waist-to-hip circumference ratio(WHR), waist circumference(WC), visceral adipose tissue(VAT)volume and subcutaneous adipose tissue(SAT) volume on abdominal CT], history of prior abdominal surgery, constipation, experience of the colonoscopist, quality of bowel preparation, diverticulosis and time required to reach the cecum were analyzed. CIT was categorized as longer than 10 min(prolonged CIT) and shorter than or equal to 10 min, and then the factors that required a CIT longer than 10 min were examined.RESULTS A total of 1678 participants were enrolled. The mean age was 50.42 ± 9.931 years and 60.3% were men. The mean BMI, WHR, WC, VAT volume and SAT volume were 23.92 ± 2.964 kg/m2, 0.90 ± 0.076, 86.95 ± 8.030 cm, 905.29 ± 475.220 cm3 and 1707.72 ± 576.550 cm3, respectively. The number of patients who underwent abdominal surgery was 268(16.0%). Colonoscopy was performed by an attending physician alone in 61.9% of cases and with the involvement of a fellow in 38.1% of cases. The median CIT was 7 min(range 2-56 min, IQR 5-10 min), and mean CIT was 8.58 ± 5.291 min. Being female, BMI, VAT volume and involvement of fellow were significantly associated with a prolonged CIT in univariable analysis. In multivariable analysis, being female(OR = 1.29, P = 0.047), lower BMI(< 23 kg/m2)(OR = 1.62, P = 0.004) or higher BMI(≥ 25 kg/m2)(OR = 1.80, P < 0.001), low VAT volume(< 500 cm3)(OR = 1.50, P = 0.013) and fellow involvement(OR = 1.73, P < 0.001) were significant predictors of prolonged CIT. In subgroup analyses for gender, lower BMI or higher BMI and fellow involvement were predictors for prolonged CIT in both genders. However, low VAT volume was associated with prolonged CIT in only women(OR = 1.54, P = 0.034).CONCLUSION Being female, having a lower or higher BMI than the normal range, a low VAT volume, and fellow involvement were predictors of a longer CIT.

ESWL for difficult bile duct stones:A 15-year single centre experience

AIM:To evaluate the efficacy of extracorporeal shock wave lithotripsy(ESWL)for the management of refractory bile duct cholelithiasis in a third level referral centre.METHODS:The clinical records of all patients treated with a second generation electromagnetic lithotripter (Lithostar Plus,SIEMENS)from October 1990 to April 2005 were evaluated.All patients were monitored during the procedure and antibiotics were administered in case of cholangitis.Theχ 2 test and logistic regression analysis were performed as appropriate.RESULTS:Two hundred and fourteen patients(102 males,112 females;mean age 74.8±0.84 years-single stone 97,multiple stones 117)underwent ESWL.The mean number of sessions and shock waves were 3.5 ±0.13 and 3477.06±66.17,respectively.The maximum stone size was 5 cm.Complete stone clearance was achieved in 192(89.7%)patients.Of the remain-ing patients 15 required surgery,2 a palliative stent and in 5 patients stone fragmentation led to effective bile drainage with clinical resolution despite incomplete clearance.Age,sex and stone characteristics were not related to treatment outcome.Major complications occurred in two patients(haemobilia and rectal bleeding) and minor complications in 25(3 vomiting,22 arrhythmias).No procedure-related deaths occurred.CONCLUSION:ESWL is a safe and effective technique for clearance of refractory bile duct stones.

Innovation of endoscopic management in difficult common bile duct stone in the era of laparoscopic surgery

Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management.In general,there are three classifications of difficult CBD stone,which are based on the characteristics of the stone(larger than 15 mm,barrel or square-shaped stones,and hard consistency),accessibility to papilla related to anatomical variations,and other clinical conditions or comorbidities of the patients.Currently,endoscopic papillary large balloon dilation(EPLBD)of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts.If failed extraction is still encountered,mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered.Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available.To our knowledge,conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches.The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.

Endoscopic retrograde cholangiopancreatography in elderly patients: Difficult cannulation and adverse events

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is a valuable therapeutic technique for pancreatobiliary diseases,and its application in the elderly is no longer limited.However,a higher incidence of procedure difficulty and periprocedural adverse events might be expected in elderly patients due to the presence of other medical disorders and the poor general condition of this population.AIM To evaluate the incidence,causes,and management of difficult biliary cannulation during ERCP in elderly patients and the role of difficult cannulation as a risk factor for adverse events.METHODS A total of 614 patients who underwent ERCP during the study period were prospectively studied and divided into two groups based on their age.One hundred and forty-six patients were aged 80 years or older and 468 patients were aged less than 80 years.The primary outcome measurements were cannulation difficulty,cannulation success rate,ERCP procedure time,and related adverse events.RESULTS There was no difference in the incidence of difficult cannulation among the two groups(32.9%vs 34.4%,P=0.765),as well as in the cannulation success rate(96.6%vs 96.8%,P=0.54).The cannulation techniques were shown to be safe and efficient in achieving successful cannulation.Logistic regression analysis showed that patients aged 80 years or older were not associated with increased adverse events;however,difficult cannulation cases[adjusted odds ratio(AOR)=3.478;95%confidence interval(CI):1.877-6.442;P<0.001]and patients with Charlson Comorbidity Index≥2(AOR=1.824;95%CI:0.993-3.349;P=0.045)were more likely to develop adverse events.In contrast,other factors including age≤65(AOR=3.460;95%CI:1.511-7.922;P=0.003),female gender(AOR=2.362;95%CI=1.089-5.124;P=0.030),difficult cannulation(AOR=4.527;95%CI:2.078-9.860;P<0.001),and patients with cholangitis(AOR=3.261;95%CI:1.204-8.832;P=0.020)were strongly associated with a higher rate of post-ERCP pancreatitis.CONCLUSION Advanced age has not been proved to be a risk factor for difficult cannulation,and secondary cannulation techniques can be safely and efficaciously utilized in this group.Patients with a Charlson Comorbidity Index≥2 and difficult cannulation are associated with an increased overall adverse events rate,while age≥80 years is not.

Full-face excavation of large tunnels in difficult conditions

Following a few preliminary remarks on the tunneling methods at the beginning of the 20th century, thesuccessful applications of the full-face method also in difficult conditions are underlined. The attention isposed on the use of a systematic reinforcement of the face and of the ground, by means of fiber-glasselements. A selection of tunnels where this method was used successfully is reported with the purposeof illustrating the wide spectrum of ground conditions where it has been applied. Then, following adescription of the main concepts behind the method, the attention moves from the so-called “heavymethod”, where deformations are restrained, to the “light method”, where deformations are allowedwith the intention to decrease the stresses acting on the primary and final linings. The progress in theapplication of the “light method” is underlined, up to the development of a novel technique, which relieson the use of a yielding support composed of top head steel sets with sliding joints and specialdeformable elements inserted in the primary lining. The well-known case study of the Saint Martin LaPorte access adit, along the Lyon-Turin Base Tunnel, is described. In this tunnel, a yield-control supportsystem combined with full-face excavation has been adopted successfully in order to cope with the largedeformations experienced during face advance through the Carboniferous formation. The monitoringresults obtained during excavation are illustrated, together with the modeling studies performed whenpaying attention to the rock mass time-dependent behavior.

Utility of single and double balloon endoscopy in patients with difficult colonoscopy: A randomized controlled trial

AIM: To compare the utility of single-balloon colonoscopy (SBC) or double-balloon colonoscopy (DBC) for difficult colonoscopies. METHODS: Between August 2008 and June 2010, patients in whom total colonoscopy failed within 30 min of insertion were assigned randomly to undergo either SBC or DBC. No sedatives were used. After the endoscopy, all patients were asked to evaluate pain during the procedure on a 10-point analog scale (1 = no pain; 10 = worst imaginable pain) with a questionnaire. The study outcomes were the cecal intubation rate and time, endoscopic findings, complications, and pain score. RESULTS: The SBC and DBC groups included 11 and 10 patients, respectively. All but one SBC patient achieved total colonoscopy successfully. The cecal intubation times were 18 min (range: 10-85 min) and 12.8 min (range: 9.5-42 min) in the SBC and DBC groups, respectively (P= 0.17). No difference was observed in the prevalence of colon polyps between the SBC and DBC groups (45% vs 30%, P = 0.66). SBC showed advanced colon cancer in the ascending colon, which was inaccessible using conventional colonoscopy. The respective pain scores were 5 (1-10) [median (range)] and 5 (1-6) in the SBC and DBC groups (P = 0.64). No complications were noted in any patient. CONCLUSION: The utility of singleand double-balloon endoscopy for colonoscopy seems comparable in patients with incomplete colonoscopy using a conventional colonoscope.

Difficult Intubation in a Patient with Dysphagia after Posterior Occipitocervical Fusion: A Case Report

The authors encountered a case involving difficult intubation during anesthesia for revision of cervical fixation angle in a 62-year-old woman, with a history of chronic rheumatoid arthritis, who experienced dysphagia after initial posterior occipitocervical fusion to correct atlantoaxial subluxation. Two days after initial surgery, she developed trismus with neck flexion and dysphagia, and underwent revision surgery. General anesthesia was planned;however, tracheal intubation using the McGrath laryngoscope and bronchofiberscope was difficult, which prolonged anesthesia induction. Narrowing of the oral and pharyngeal cavities associated with overcorrection of the cervical spine was believed to be the reason for difficulty in manipulating the tracheal intubation devices. In posterior occipitocervical fusion, intraoperative evaluation of the occipito-second cervical vertebra (O-C2) angle is reported to be useful in preventing postoperative dyspnea and/or dysphagia, and avoids the need for revision of fixation angle. However, when revision surgery is needed, selection of airway management methods and tracheal intubation devices are important considerations because patients are likely to have restricted mobility in the cervical spine and narrowing of the oral and pharyngeal cavities.

Management of difficult intravenous access:a qualitative revie

BACKGROUND:A perennial challenge faced by clinicians and made even more relevant with the global obesity epidemic,difficult intravenous access(DIVA)adversely impacts patient outcomes by causing significant downstream delays with many aspects of diagnoses and therapy.As most published DIVA strategies are limited to various point-of-care ultrasound techniques while other“tricks-of-the-trade”and pearls for overcoming DIVA are mostly relegated to informal nonpublished material,this article seeks to provide a narrative qualitative review of the iterature on DIVA and consolidate these strategies into a practical algorithm.METHODS:We conducted a literature search on PubMed using the keywords“difficult intravenous access”,“peripheral vascular access”and“peripheral venous access”and searched emergency medicine and anaesthesiology resources for relevant material.These strategies were then categorized and incorporated into a DIVA algorithm.RESULTS:We propose a Vortex approach to DIVA that is modelled after the Difficult Airway Vortex concept:starting off with standard peripheral intravenous cannulation(PIVC)techniques,progressing sequentially on to ultrasound-guided cannulation and central venous cannulation and finally escalating to the most invasive intraosseous access should the patient be in extremis or should best efforts with the other lifelines fail.CONCLUSION:DIVA is a perennial problem that healthcare providers across various disciplines will be increasingly challenged with.It is crucial to have a systematic stepwise approach such as the DIVA Vortex when managing such patients and have at hand a wide repertoire of techniques to draw upon.

Immediate balloon deflation method in endoscopic papillary large balloon dilation for extraction of difficult bile duct stones

Background/Aims: Recently, endoscopic papillary large balloon dilation (EPLBD) using a large balloon (12 - 20 mm) for extraction of difficult common bile duct (CBD) stones has been widely accepted with favorable outcomes. However, there is no consensus with regard to the ballooning time. The aim of our study was to evaluate the efficacy and safety of immediate balloon deflation in EPLBD for the treatment of difficult bile duct stone. Methods: This was a retrospective study of 80 consecutive patients with bile duct stones who were treated with an immediate balloon deflation method in EPLBD combined with endoscopic sphincterotomy (EST) between January 2010 and December 2012. Overall success rate, success rate at first ERCP, and the frequency of mechanical lithotripsy for complete stone removal were assessed for efficacy and safety was evaluated by assessing major complications. Results: Overall success rate for complete stone removal was high (78/80, 97.5%) and success rate for complete stone removal at first ERCP was 86.3% (69/80). The use of mechanical lithotripsy was 0% (0/80). The overall complication rate was favorable (5/80, 6.3%). PostERCP pancreatitis was observed in 3 patients (two: mild, one: moderate). In subgroup analysis, the presence of periampullary diverticulum was the only factor affecting the success rate at first ERCP. Conclusion: This study demonstrated the favorable outcome of immediate balloon deflation for treatment of difficult CBD stones and can be considered for clinical application.

Use of Laryngeal Mask Airway in the Management of a Difficult Airway: A Case Report

Background: Difficulty in management of the airway occurs most frequently in patients who have Mallampati grade III and IV, and other unfavourable airway findings like short neck, restriction in range of motion of the temporoman-dibular joints and inadequate neck flexion and extension. Because of unavailability of fibreoptic bronchoscopes or inexperience in their use, laryngeal mask airway (LMA) has become a common and acceptable airway management option. This is a case report of a postmenopausal woman who had her airway managed with LMA following initial failed intubation necessitating a rescheduling of the operation. Result: The patient had a successful surgery and postoperative recovery was uneventful. Conclusion: The LMA is a useful option in the management of an anticipated or unexpected difficult airway, especially in resource-poor settings where fibreoptic bronchoscopes may not be readily available.

Reinke’s Oedema Presenting as Stridor: Implications for Otolaryngologists in Difficult Airway

We demonstrated the importance of managing a patient who presented with stridor due to severe Reinke’s oedema. The concept of managing difficult airway has thus been introduced for the otolaryngologists according to a plan of action as described by the American Society of Anaesthesiologist’s difficult airway algorithm. Methods: A case report of interest and review of literature. PubMed search with keywords of difficult airway, stridor, awake intubation and Reinke’s oedema was used. Result: Management of an anticipated difficult airway with awake fiberoptic intubation with backup strategies of direct laryngoscopies with Eshmann stylet and awake invasive intubation is highlighted. Conclusion: This case report demonstrated a definitive strategy of securing a difficult airway with obstruction at the glottis and highlighted the role of teamwork between otolaryngologist and anaesthesiologist to secure difficult airway.

Change in management of predicted difficult airways following introduction of video laryngoscopes

AIM To determine if video laryngoscopy(VL) has significantly impacted management of difficult airways by decreasing the rate of awake fiberoptic intubation(FOI). METHODS Anesthetic records of 3723 patients who underwent general anesthesia at Rush University Medical Center were reviewed over a 2-mo period prior to the introduction of VLs in 2009("pre-VL" group) and over the same 2-mo period after the introduction of VLs in 2012("postVL" group). Patient records with predicted difficult air-ways based on pre-operative airway examination were analyzed. The primary outcome was rate of awake FOI.RESULTS To control for possible factors that may influence the FOI rate, a logistic regression was performed with these factors included as covariates. The rate of awake FOI was 13.1% in pre-VL group compared to 9.0% in post-VL group. Although this decrease was not statistically significant individually(P = 0.1768), it showed a trend toward significance when covariates were accounted for(P = 0.0910). Several factors predicting a higherlikelihood of awake FOI were found to be statistically significant: Morbid obesity(larger BMI P = 0.0154, OR = 1.5 per 10 point BMI increase), male gender(P = 0.0026, OR = 3.0) and a higher el-Ganzouri airway score(P = 0.0007, OR = 1.5). Although VLs were seen to be used to intubate 51% of predicted difficult airways, the rate of awake FOI has not significantly changed.CONCLUSION Although VL may continue to grow in popularity, the most difficult airways are still managed using awake FOI.

Strategies to manage the difficult colonoscopy

During endoscopy,an endoscopist is inevitably faced with the occasional“difficult colonoscopy,”in which the endoscopist finds it challenging to advance the endoscope to the cecum.Beyond optimization of technique,with minimized looping,minimal insufflation,sufficient sedation,and abdominal splinting when needed,sometimes additional tools may be needed.In this review,we cover available techniques and technologies to help navigate the difficult colonoscopy,including the ultrathin colonoscope,rigidizing overtube,balloon-assisted colonoscopy and the abdominal compression device.

Difficult-to-Treat-Depression—Perceptions of GPs and GP Trainees

Introduction: GPs are often the first contact point for mental health concerns. Training to qualify as a GP involves completing a three-to-four year program. Among other things, the training program may include a six-hour mental health training workshop. The study’s purpose was to compare GPs’ and Trainees’ perceptions of difficult-to-treat-depression (DTTD). Methods: Using a semi-structured interview schedule comprising six questions, 10 GPs and six Trainees participated in focus groups or telephone interview. To understand participants’ perspectives, data were analyzed using the Framework Method. Findings: Trainees were less clear than GPs about the meaning of DTTD and other diagnostic terms. GPs’ diagnosis included querying diagnosis and treatment options. Trainees’ experience was limited but they raised barriers including non-response to various treatment trials. Both groups identified management difficulties including: doctor shopping, suicide risk, patients not being well informed;with management difficulties exacerbated by limited access/referring to health professionals, cost and/or unavailability of bulk billing. While some GPs and Trainees had heard of an illness management model or chronic illness model, few used a model. Most reported limited referring to psychiatrists, mainly because of cost and/or limited availability. GPs were more likely to refer to other health professionals and use pharmacological and complementary therapies. Both groups discussed the impact of external factors including cultural factors, patient compliance, treatment failure, and the importance of the relationship between the patient and the professional. Trainees were more likely to stress the importance local clinical guidelines. Discussion and Conclusion: Despite the small size and limited nature, this research provides insight into some of the similarities and differences of GPs’ and Trainees’ experiences and understanding of DTTD. This may have implications for training providers, clinical supervisors and Trainees, and suggests that enhancement in the role of mental health training may be relevant.

Value of Topology Approach to Diagnose of CAD Based on Magnetocardiographic Current Distribution Maps in Difficult-to-Diagnose Patients

Objective: The purpose of this work is to examine the usefulness of the topological approach for analysis of current density maps during ST-T interval in detection of coronary artery disease (CAD) in patients with proved CAD but normal results of routine tests. Materials and Methods: The patient group included 123 patients. Coronary angiography was done due to chest pain. The control group consisted of 124 healthy volunteers. The MCG test was done by 4-channels MCG system installed at unshielded setting. An integral topological index Kideal, consisting of 4 parameters, has been counted. Results and Conclusions: It is shown that Kideal was higher in patient group compared to control one. Sensitivity was 87%, and specificity was 64%. The topological analysis of MCG current density maps is a valuable tool in noninvasive detection of CAD in difficult-to-diagnose patients with uninformative results of routine tests.

Use of McGrath^(■) MAC Video Laryngoscope for Nasotracheal Intubation in Patients for Whom Intubation Was Expected to Be Difficult Due to the Limited Mouth Opening

McGrath? MAC video laryngoscope (McG) has been used for orotracheal intubation in both normal patients and patients for whom intubation was expected to be difficult, and has been reported to provide improved visibility of the glottis during tracheal intubation. There are some reports that normal nasotracheal intubation is easier with McG than with macintosh laryngoscope (ML). The usefulness of McG for nasotracheal intubation is beginning to be recognised. We experienced three cases using McG in patients for whom intubation was expected to be difficult due to the limited mouth opening and using McG for those patients enabled smooth nasotracheal intubation. McG provides good visual field during nasotracheal intubation, and is less invasive to the patient.

Unexpected difficult airway due to severe upper tracheal distortion:A case report

BACKGROUND Difficult airway is a significant cause of anesthesia-associated death and disability.Currently,physical examinations of thyromental distance,mouth opening,Mafampaii classification,etc.combined with X-ray,computed tomography(CT),and other imaging technologies are mainly used to evaluate difficult airways.However,in many special cases,i.e.,emergency surgery,imaging examinations cannot be completed preoperatively.Such patients’airway can only be evaluated through general physical examination,which inevitably increases the likelihood of an unexpected difficult airway during anesthesia.CASE SUMMARY We report a rare case of difficult intubation because of severe upper trachea distortion after induction.Emergency holmium laser lithotripsy was performed under transurethral ureteroscopy because the patient had anuria for 4 d and a creatinine level of 890μmol/L.Due to the urgency of the condition,chest radiography or chest CT was not examined before surgery and the anesthesiologist did not evaluate the airway adequately,resulting in an unexpected difficult airway.CONCLUSION The incidence of tracheal malformation and tracheal stenosis is extremely low,but the risk of hypoxia and even death due to difficult airways is extremely high for such patients.It is recommended to complete preoperative imaging examinations of the airway.For life-threatening emergency patients,a pre-anesthesia reassessment should be performed and surgeons should be prepared to prevent and manage the difficult airway.

Airway ultrasound for patients anticipated to have a difficult airway:Perspective for personalized medicine

Airway ultrasound allows for precise airway evaluation,particularly for assessing the difficult airway and the potential for front of neck access.Many studies have shown that identification of the cricothyroid membrane by airway ultrasound is more accurate than digital palpation.However,no reports to date have provided clinical evidence that ultrasound identification of the cricothyroid membrane increases the success rate of cricothyroidotomy.This is a narrative review which describes patients with difficult airways for whom airway ultrasound may have been useful for clinical decision making.The role of airway ultrasound for the evaluation of difficult airways is summarized and an approach to the use of ultrasound for airway management is proposed.The goal of this review is to present practical applications of airway ultrasound for patients predicted to have a difficult airway and who undergo cricothyroidotomy.