Portal venous gas resulting from umbilical vein catheterization in a very-low-birth-weight infant with no interruption in early feeding

Introduction Portal venous gas(PVG)is common in necrotizing enterocolitis and occasionally occurs in neonates after umbilical vein catheterization(UVC).Therefore,determining the cause of PVG requires further clinical evaluation in these cases.Case presentation We report the case of a very-low-birth-weight infant who underwent UVC after birth.PVG was an unexpected finding on ultrasound following catheterization.The UVC was immediately removed and replaced with a peripherally inserted central catheter.The infant’s physical examination was unremarkable.Bedside X-ray revealed neither PVG nor pneumatosis intestinalis,which would indicate the onset of necrotizing enterocolitis.After full evaluation,breastfeeding was started on the same day.The infant did not develop feeding intolerance,necrotizing enterocolitis,or other disorders.Conclusion PVG occasionally occurs in neonates who undergo UVC and is considered to be caused by exogenous gases.PVG is more easily detected with ultrasound than with X-ray and does not affect early feeding in premature infants.

Application of the “Three Threes” Method in Clinical Teaching of Internal Jugular Vein Puncture

Objective: To clarify the role of the “Three Threes” method in clinical teaching of internal jugular vein puncture and explore improvements in teaching methods. Methods: A doctor was assigned to the induction room of the Second Affiliated Hospital of Naval Medical University (Shanghai Changzheng Hospital) for two months. The time required for catheterization, the first puncture success rate, and occurrence of puncture-related complications were compared before and after learning the “Three Threes” method. Results: Using the “Three Threes” method reduced the catheterization time by 43%, increased the first puncture success rate by 17%, and led to fewer puncture-related complications. Conclusion: The application of the “Three Threes” method not only improves the success rate of internal jugular vein puncture but also reduces complications, making it easier for students to master the technique.

Modification of the right subclavian vein catheterization and its anatomic basis and techniques

Background Several million subclavian-vein catheters are placed in patients each year to enable caregivers to administer chemotherapy, total parenteral nutrition, or long-term antibiotics or to manage preoperative fluids. Subclavian venipuncture requires the position of a deep vein to be identified with only surface landmarks. But the traditional right subclavian vein (RSV) catheterization (primitive procedures) is not the answer for all patients. The precise location of the vein is not known, and it is important to select the most appropriate method to achieve central venous access safely in any given patient. To modify the primitive procedures of the RSV catheterization for greater success and reduce the complications, anatomic studies and ultrasonography were conducted and clinical applications were validated. Methods Anatomical observation and measurement of the RSV and its adjacent structures were performed on 20 adult cadavers according to modified procedures. The RSV catheterization of 2900 cases was carried out by the modified procedure, 500 of these cases were observed by ultrasonography after the operation. Results The anatomical studies and clinical application showed that the insertion point differs from the bodily form of fatness or leptosome. The clinical data revealed that in the 2900 cases which were performed with the modified approach, the success rate was 98.90% (2868 cases), the failure rate was 1.10% (32 cases), and the complication rate is 0.79% (23 cases), and the catheterization time is (31.2±10.5) minutes. Five hundred and sixty cases of the RSV catheterization were carried out by the recommended insertion procedure; the results were compared with the modified approach and the traditional approach. The successful rate of the traditional approach was 73.0%, of which the complication rate was 6.1%; the two approaches were significantly different (successful rate: χ 2=626.642, P <0.01; complication rate: χ 2=80.708, P <0.01). Conclusions The modified RSV catheterization is characterized with a higher success rate and less complications, and the insertion procedure differs from the bodily form of fatness or leptosome.

Upper extremity deep vein thrombosis:An intensivist’s perspective

Upper extremity deep vein thrombosis(UEDVT)is less common than lower extremity DVT but is a cause of significant morbidity and mortality in intensive care unit patients.Increasing cancer incidence,prolonged life expectancy and increasing use of intravascular catheters and devices has led to an increased incidence of UEDVT.It is also associated with high rates of complications like pulmonary embolism,post-thrombotic syndrome and recurrent thrombosis.Clinical prediction scores and D-dimer may not be as useful in identifying UEDVT;hence,a high suspicion index is required for diagnosis.Doppler ultrasound is commonly employed for diagnosis,but other tests like computed tomography and magnetic resonance imaging venography may also be required in some patients.Contrast venography is rarely used in patients with clinical and ultrasound findings discrepancies.Anticoagulant therapy alone is sufficient in most patients,and thrombolysis and surgical decompression is seldom indicated.The outcome depends on the cause and underlying comorbidities.

Radiofrequency Ablation Mapping with Circumferential Catheter for Paroxys- mal Atrial Fibrillation Originating From the Pulmonary Veins

Objectives To assessed the feasibility and effectiveness of electrophysiological mapping of pulmonary veins with a circumferential 10 - electrode catheter and radiofrequency catheter ablation therapy for patients with paroxysmal atrial fibrillation. Background Standard mapping and ablation of focal sources of atrial fibrillation are associated with very long procedure times and low efficacy. Mapping and ablation pulmonary veins guide with a circular catheter could overcome these limitations. Methods 16 patients [male 11, female 5, mean age (51 ±14. 5) years] with paroxysmal atrial fibrillation refractory to antiarrhythmic drugs were included in this group. A circumferential 10 - electrode catheter was used to pulmonary vein mapping during sinus rhythm or CSd pacing to determine the origin of atrial premature contractions. When the ablative target pulmonary vein was found, the pulmonary vein potentials' distribution and activation were assessment pulmonary veins' ostial ablation was performed at the segments showing earliest activation of pulmonary vein potentials. The end point was designed: 1) elimination of pulmonary vein potential; 2) pulmonary vein potential dissociation from atrial waves; 3) atrial ectopic beats disappear. Results A total of 36 pulmonary veins were ablated, including 16 left superior, 12 right superior, 7 left inferior and 1 right inferior. 1 pulmonary vein in 2 patients was ablated, 2 pulmonary veins in 8 patients were ablated, 3 pulmonary veins were ablated in 5 patients and 4 pulmonary veins were ablated in 1 pa- tient. Procedure duration and fluoroscopy time respectively were 186. 7±63. 8 min and 51. 5±15. 0 min. During the follow-up 1-12 months, 11 patients (68. 7 % ) were free of AF without any antiarrhythmic drugs, 2 of them were reablation, effective in 3/16 (18. 7 % ) and unsuccessful in 2/16 (12. 6 % ) . 2 cases recurred with atrial premature, 1 was treated with amiodarone and the other was repeat electrophysiologi-cal mapping and ablation, 5 cases with paroxysmal a-trial fibrillation recurred, 3 of them were treated with amiodarone (2 cases) or sotalol (1 case) , one was implantled with DDDR pacemaker (having programmer of anti - atrial fibrillation), one was repeat ablation. PV's diameter in 2 of them reduced more than 50 % , but they were asymptomatic during the follow - up period. 1 case had pneumothorax complication and disappeared after 7 days. Conclusions This study suggests that careful mapping and elimination of these ectopic foci under the guide of circular catheter may have higher success rate and splendid future.

Flexible Subclavian Artery Closure for an Inadvertent Injury to the Internal Mammary Artery During Internal Jugular Vein Catheterization

Central vein catheter （CVC） placement, which is widely utilized in clinical departments, is also highly important in preoperative preparations for radiofrequency catheter ablation （RFCA）. The internal jugular vein or subclavian vein is the routine target. Arterial injury is not uncommon during the procedure but is potentially devastating in spite of the safety and advantages of the Seldinger technique. Compressing of the airway by a hematoma, as well as hemothorax, pseudoaneurysm, arteriovenous fistula, stroke, and even death, has been well-described.

Clinical analysis of central venous catheter-related infections in patients in the emergency ICU

BACKGROUND:Catheter-related infection(CRI)of the central vein is a common cause of nosocomial infection.This study was undertaken to investigate the pathogen culturing and risk factors of CRI in emergency intensive care unit(EICU)in order to provide the beneficial reference.METHODS:From January 2008 to December 2010,a total of 1 363 patients were subjected to catheterization.In these patients,the peak CRI rate of the patients was determined by bacterial cultivation and blood bacterial cultivation.RESULTS:CRI happened in 147 of the 1 363 patients using the central venous catheter.The peak rate of CRI was 10.79%,with an incidence of 3.05 episodes per 1 000 catheter days.Of the147 patients,46.94%had gram-negative bacilli,40.14%had gram-positive cocci,and 12.92%had fungi.Unconditional logistic regression analysis suggests that multiple catheterization,femoral vein catheterization,the application of multicavity catheter,and the duration of catheterization were the independent risk factors for CRI.CONCLUSION:The risk factors for catheter-related infections should be controlled to prevent the occurrence of nosocomial infection.

Results of Atrial Fibrillation Ablation in Patients With or Without a History of Atrial Flutter

Objectives There are two kind of atrial flutter during circumferential ablation for atrial fibrillation （AF）： new onset left atrial flutter （LAFL）, with a history of atrial flutter （AFL）. What is the relationship of AFL and AF？ Whether there are some differences in clinical course and mechanism between the new onset LAFL and the with a history of AFL remained unclear. The aim of this study was to assess the impacts of circumferential ablation on the occurrence of arrhythmias in follow-up in 2 groups： （1） patients with a history of AFL and AF, and （2） patients with new onset LAFL. Methods Data from 465 patients who had circumferential pulmonary vein ablation （CPVA） or segmental pulmonary vein ablation （SPVA） were analyzed. Patients with a history of AFL ablation and patients who had concomitant AFL ablation were included from analysis. Forty-one patients constituted the history of AFL group （group 1, aged 57±13 years, 7 females） and twenty-eight patients constituted the new onset LAFL group （group 2, aged 55±12 years, 6 females）, bipolar recordings were obtained from the tricuspid annulus, coronary sinus, interatrial septum and left atrium. Target sites were identified by early, fragmented or double potentials and by concealed entrainment. Linear lesions were created between target sites and nearby anatomical barriers （1） typical atrial flutter （cycle length, 242± 39 ms）. cavotricuspid isthmus ablation was performed. （2） new onset LAFL （cycle length, 282±153 ms）. 20 episodes of AAFs were documented in 20/28 （71.4%） patients. Target sites were identified around pulmonary veins （n=10）, gap in linear lesion （n=7）, left atrial roof lines （1 case）. For those cases the ablation line between PV and mitral annulus was performed. Patients in Group 2 had larger left atria, incidence of AFL pre-CPVA, and lower ejection fraction. Results There was no significant difference in post-CPVA AF recurrence between Groups 1 and 2, but AFL incidence after CPVA was higher in Group 2 （33% vs 4%, P 〈 0.0001）. Ablation of AFL in group 1 patients resulted in an 88% acute success rate （group2, 86%） and 12% （group2,17%） recurrence over a mean follow-up of 287 ±101 days.Condusions In patients with a history of atrial flutter, post-CPVA AF recurrence is similar to patients with new onset LAFL. However, LAFL is associated with a higher recurrence of AFL after PVAI. In a significant number of patients with LAFL, mitral Isthmus ablation is needed and can be performed effectively. Its eleetrophysiologieal eonse-quenees could be considered analogus to the results achieved by eavotrieuspid isthmus ablation.

Impact of misplaced subclavian vein catheter into jugular vein on transpulmonary thermodilution measurement variables

Objective： The subclavian vein （SCV） is usually used to inject the indicator of cold saline for a transpul- monary thermodilution （TPTD） measurement. The SCV catheter being misplaced into the internal jugular （IJV） vein is a common occurrence. The present study explores the influence of a misplaced SCV catheter on TPTD variables. Methods： Thirteen severe acute pancreatitis （SAP） patients with malposition of the SCV catheter were enrolled in this study. TPTD variables including cardiac index （CI）, global end-diastolic volume index （GEDVI）, intrathoracic blood volume index （ITBVI）, and extravascular lung water index （EVLWl） were obtained after injection of cold saline via the misplaced SCV catheter. Then, the misplaced SCV catheter was removed and IJV access was constructed for a further set of TPTD variables. Comparisons were made between the TPTD results measured through the IJV and mis- placed SCV accesses. Results： A total of 104 measurements were made from TPTD curves after injection of cold saline via the IJV and misplaced SCV accesses. Bland-Altman analysis demonstrated an overestimation of ＋111.40 ml/m2 （limits of agreement： 6.13 and 216.70 ml/m2） for GEDVI and ITBVI after a misplaced SCV injection. There were no significant influences on CI and EVLWI. The biases of ＋0.17 L/（min.m2） for CI and ＋0.17 ml/kg for EVLWI were re- vealed by Bland-Altman analysis. Conclusions： The malposition of an SCV catheter does influence the accuracy of TPTD variables, especially GEDVI and ITBVI. The position of the SCV catheter should be confirmed by chest X-ray in order to make good use of the TPTD measurements.

Recurrent atrial tachycardia and atrial fribrillation after circumferential pulmonary vein ablation:What’s the difference?

Background Recurrent atrial tachyarrhythmia （ATa） after circumferential pulmonary vein ablation （CPVA） includes atrial tachycardia （AT） and atrial fribrillation （AF）. However, whether there are some differences in clinical course and mechanisms between the recurrent AT and the recurrent AF remained unclear. This study was conducted to investigate the incidence, mechanism, clinical course of the recurrent AT and AF in patients under CPVA.Methods One hundred and thirty consecutive patients （M/F = 95/35 ） with highly symptomatic ano multiple antiarrhythmic drugs （AADs） refractory paroxysmal （ n = 91 ） or persistent （ n = 39 ） AF were included. The ablation protocol consisted solely of two continuous circular lesions around the ipsilateral pulmonary veins （PV） guided by CARTO system. The endpoint of CPVA is PV isolation. For patients with recurrent ATa within 2 months after the initial procedure, cardioversion with direct current was attempted if the ATa lasted for more than 24 hours. A repeat ablation procedure was performed only for patients with AADs refractory recurrent ATa and at least followed up for 2 months after the initial procedure.Results Within 2 months after the initial procedure, 52 patients （40. 0% ） had experienced episodes of symptomatic recurrent ATa. Among them, 23 patients （44.2%） with recurred AT alone （AT group ）, 14 patients （26.9%） with recurred AF alone （AF group）, and 15 patients （28.8%） with recurred AT and AF （AT plus AF group）. The delayed cure rate （65.2%） in AT group was significant higher than that in AF group （21.4%, P〈0.05） and AF plus AT group （26.7%, P 〈0.05）. A repeat ablation was performed in 21 patients, including 6 patients with recurrent AT alone, 8 patients with recurrent AF alone, and 7 patients with recurrent AF plus AT. The mean number of PV gaps was 1.2 ± 0. 4 in AT group, which was significantly lower than that in AF group （2.6 ± 0. 7, P 〈 0.05） and AF plus AT group （2.0 ± 0.6, P 〈 0.05）. Delayed cure rate and number of PV gaps between AF group and AF plus AT group were comparable （P 〉 0.05 ）. Conclusions Present study indicates that recurrent AT and AF after CPVA have the different clinical course and different electrophysiological findings during repeat procedure as follows： （1）After CPVA, spontaneous resolution of recurrent ATa was mainly found in patients with recurrent AT alone （about two thirds patients）. （2） The type of recurrent ATa after CPVA is associated with the numberof PV gaps.

Percutaneous repair of inadvertent subclavian artery cannulation： a case report

Although catheterization of the subclavian vein is a common procedure, it might be associated with life-threatening complications including accidental cannulation of subclavian artery. Rash sheath removal could result in fatal hemorrhage. We report a case of inadvertent 6F sheath cannulation of the right subclavian artery during a radiofrequency catheter ablation procedure and successful repair of the cannulation by Angio-Seal STS plus （St. Jude Medical, St. Paul, MN, US）, a collagen-base vascular closure device.