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Journal of Vascular Surgery. Venous and... Nov 2019Misuse of vascular dilators during the placement of central venous catheters has been infrequently reported and can lead to devastating intrathoracic hemorrhage and...
BACKROUND
Misuse of vascular dilators during the placement of central venous catheters has been infrequently reported and can lead to devastating intrathoracic hemorrhage and death. These injuries should be preventable in most cases. If a major intrathoracic vascular injury is recognized intraoperatively, less invasive treatment options are available to minimize the consequences.
METHODS
The records of 20 patients who suffered 21 major vascular injuries during insertion of central venous catheters, ports, or dialysis catheters and resulted in malpractice claims over the course of 8 years were analyzed to determine the mechanism of injury, the timing of diagnosis, and how these injuries were treated. How the injury could have been prevented, why earlier diagnosis was not made, and what treatment options were possible were also examined.
RESULTS
Twelve women and eight men were documented to have sustained intrathoracic major venous injuries during catheter insertions. There were five injuries to the superior vena cava, six to the right innominate vein, and 10 to the left innominate vein. All procedures were done using fluoroscopic guidance, and resistance to passage of the dilators was documented in eight cases. In most cases, the operator reported inserting the dilators to their maximum length. In four cases, the catheter could be seen intraoperatively in the thoracic cavity. Bleeding was diagnosed in the operating room in 11 cases, in the postanesthesia care unit in seven cases, and on postoperative days 2 and 5 after misplaced catheters were removed. Ten patients underwent thoracotomies and one patient each underwent thoracoscopy and placement of a covered stent in an attempt to stop the hemorrhage. Eight patients died before the diagnosis was made. Seventeen patients died.
CONCLUSIONS
In spite of U.S. Food and Drug Administration warnings, dilators are still inserted too far in patients, resulting in devastating hemorrhage. These complications are preventable if proper technique is used. When a catheter is noted to be misplaced, it must not be removed before either a covered stent or thoracoscopy is available; otherwise, uncontrolled hemorrhage into the chest may occur. If a patient becomes unstable in the operating room or immediate postoperative period injury to a major vein must be considered and corrected quickly.
Topics: Brachiocephalic Veins; Catheterization, Central Venous; Central Venous Catheters; Dilatation; Female; Hemostatic Techniques; Humans; Male; Retrospective Studies; Risk Factors; Time Factors; Treatment Outcome; Vascular System Injuries; Vena Cava, Superior
PubMed: 31471280
DOI: 10.1016/j.jvsv.2019.06.020 -
Journal of Vascular Surgery Mar 2021To describe our technique, evaluate access related complications and factors contributing to adverse outcomes in patients undergoing retroperitoneal anterior lumbar...
OBJECTIVE
To describe our technique, evaluate access related complications and factors contributing to adverse outcomes in patients undergoing retroperitoneal anterior lumbar interbody fusion (ALIF).
METHODS
We conducted a retrospective analysis of prospectively collected data on patients undergoing ALIF at our institution from January 2008 to December 2017. Access was performed by a vascular surgeon who remained present for the duration of the case. Data collected included patients' demographics, comorbidities, exposure related complications and ileus. Study end points included major adverse events and minor complications. Major adverse events included any vascular injuries requiring repair, bowel and ureter injuries, postoperative bleeding requiring reoperation, myocardial infarction, stroke, venous thromboembolism (pulmonary embolism/deep venous thrombosis), wound dehiscence, and death. Minor complications included postoperative paralytic ileus, urinary tract infections, and surgical site infections. The incidence of incisional hernia was also evaluated.
RESULTS
During this period, 1178 patients (514 males and 664 females; mean age, 54.1 ± 13.8 years) underwent a total of 2352 levels ALIF at our institution (single level, 422 patients; 2 levels, 450; 3 levels, 205; 4 levels, 98; 5 levels, 6; 6 levels, 1; and 7 levels, 1). The median estimated blood loss was 25 mL (interquartile range, 25-50). There were 57 exposure-related complications (4.8%), including vascular injuries (venous, 13; arterial, 4) in 17 patients (1.4%), bowel injuries in three patients (serosa tear in two and arterial embolization with subsequent bowel ischemia in one). Eleven of the 13 venous injuries (84.6%) occurred while exposing the L4 to L5 lumbar level. Two of the four patients with arterial injuries developed acute limb ischemia requiring embolectomy. One embolized to the superior mesenteric artery and underwent bowel resection. Twenty patients (1.7%) developed venous thromboembolism, two of whom had sustained left iliac vein injury during exposure. Sixteen patients (1.4%) developed a retroperitoneal hematoma/seroma with nine requiring evacuation in the operating room. Thirty-six patients (3.1%) developed postoperative ileus, defined as an inability to tolerate diet on postoperative day 3. Four patients (0.4%) had a postoperative myocardial infarction, and two had a stroke and two (0.17%) died within the first 30 postoperative days. Thirty-one patients developed incisional complications, including surgical site infection in 24 and incisional hernia in 7.
CONCLUSIONS
Our findings suggest that ALIF exposure can be performed safely with a relatively low overall complication rate. The majority of vascular injuries associated with this procedure are venous in nature, occurring predominantly while exposing the L4 to L5 level and can be safely addressed by an experienced vascular team.
Topics: Adult; Aged; Arteries; Female; Humans; Ileus; Lumbar Vertebrae; Male; Middle Aged; Retrospective Studies; Risk Assessment; Risk Factors; Spinal Fusion; Stroke; Surgical Wound Infection; Time Factors; Treatment Outcome; Vascular System Injuries; Veins
PubMed: 32707392
DOI: 10.1016/j.jvs.2020.06.129 -
Biochemical and Biophysical Research... May 2020Smoke inhalation injury (SII) affects more than 50,000 people annually causing carbon monoxide (CO) poisoning. Although the increased blood level of carboxyhemoglobin...
Blood carboxyhemoglobin elimination curve, half-lifetime, and arterial-venous differences in acute phase of carbon monoxide poisoning in ovine smoke inhalation injury model.
Smoke inhalation injury (SII) affects more than 50,000 people annually causing carbon monoxide (CO) poisoning. Although the increased blood level of carboxyhemoglobin (CO-Hb) is frequently used to confirm the diagnosis of SII, knowledge of its elimination in the acute phase is still limited. The aim of this study is to determine CO-Hb elimination rates and their differences in arterial (aCO-Hb) and mixed-venous (vCO-Hb) blood following severe SII in a clinically relevant ovine model. Forty-three chronically instrumented female sheep were subjected to SII (12 breaths, 4 sets) through tracheostomy tube under anesthesia and analgesia. After the SII, sheep were awakened and placed on a mechanical ventilator (FiO = 1.0, tidal volume 12 mL/kg, and PEEP = 5cmHO) and monitored. Arterial and mixed-venous blood samples were withdrawn simultaneously for blood gas analysis at various time points to determine CO-HB half-lifetime and an elimination curve. The mean of highest aCO-Hb level during SII was 70.8 ± 13.9%. The aCO-Hb elimination curve showed an approximated exponential decay during the first 60 min. Per mixed linear regression model analysis, aCO-Hb significantly (p < 0.001) declined (4.3%/minute) with a decay constant lambda of 0.044. With this lambda, mean lifetime and half-lifetime of aCO-Hb were 22.7 and 15.7 min, respectively. The aCO-Hb was significantly lower compared to vCO-Hb at all-time points (0-180 min). To our knowledge, this is the first report describing CO-Hb elimination curve in the acute phase after severe SII in the clinically relevant ovine model. Our data shows that CO-Hb is decreasing in linear manner with supportive mechanical ventilation (0-60 min). The results may help to understand CO-Hb elimination curve in the acute phase and improvement of pre-hospital and initial clinical care in patients with CO poisoning.
Topics: Acute Disease; Animals; Arteries; Carbon Monoxide Poisoning; Carboxyhemoglobin; Disease Models, Animal; Female; Half-Life; Hemodynamics; Sheep; Smoke Inhalation Injury; Veins
PubMed: 32199614
DOI: 10.1016/j.bbrc.2020.03.048 -
Scandinavian Journal of Trauma,... Jun 2023Veno-arterial carbon dioxide tension difference (ΔPCO) and mixed venous oxygen saturation (SvO) have been shown to be markers of the adequacy between cardiac output and... (Observational Study)
Observational Study
BACKGROUND
Veno-arterial carbon dioxide tension difference (ΔPCO) and mixed venous oxygen saturation (SvO) have been shown to be markers of the adequacy between cardiac output and metabolic needs in critical care patients. However, they have hardly been assessed in trauma patients. We hypothesized that femoral ΔPCO (ΔPCO) and SvO (SvO) could predict the need for red blood cell (RBC) transfusion following severe trauma.
METHODS
We conducted a prospective and observational study in a French level I trauma center. Patients admitted to the trauma room following severe trauma with an Injury Severity Score (ISS) > 15, who had arterial and venous femoral catheters inserted were included. ΔPCO SvO and arterial blood lactate were measured over the first 24 h of admission. Their abilities to predict the transfusion of at least one pack of RBC (pRBC) or hemostatic procedure during the first six hours of admission were assessed using receiver operating characteristics curve.
RESULTS
59 trauma patients were included in the study. Median ISS was 26 (22-32). 28 patients (47%) received at least one pRBC and 21 patients (35,6%) had a hemostatic procedure performed during the first six hours of admission. At admission, ΔPCO was 9.1 ± 6.0 mmHg, SvO 61.5 ± 21.6% and blood lactate was 2.7 ± 1.9 mmol/l. ΔPCO was significantly higher (11.6 ± 7.1 mmHg vs. 6.8 ± 3.7 mmHg, P = 0.003) and SvO was significantly lower (50 ± 23 mmHg vs. 71.8 ± 14.1 mmHg, P < 0.001) in patients who were transfused than in those who were not transfused. Best thresholds to predict pRBC were 8.1 mmHg for ΔPCO and 63% for SvO. Best thresholds to predict the need for a hemostatic procedure were 5.9 mmHg for ΔPCO and 63% for SvO. Blood lactate was not predictive of pRBC or the need for a hemostatic procedure.
CONCLUSION
In severe trauma patients, ΔPCO and SvO at admission were predictive for the need of RBC transfusion and hemostatic procedures during the first six hours of management while admission lactate was not. ΔPCO and SvO appear thus to be more sensitive to blood loss than blood lactate in trauma patients, which might be of importance to early assess the adequation of tissue blood flow with metabolic needs.
Topics: Adult; Aged; Female; Humans; Male; Middle Aged; Blood Gas Analysis; Carbon Dioxide; Femoral Artery; Femoral Vein; Hemorrhage; Hemostatics; Injury Severity Score; Lactic Acid; Oxygen; Prospective Studies; Wounds and Injuries; Predictive Value of Tests
PubMed: 37340485
DOI: 10.1186/s13049-023-01095-9 -
Circulation. Arrhythmia and... Jun 2022Phrenic nerve palsy is a well-known complication of cardiac ablation, resulting from the application of direct thermal energy. Emerging pulsed field ablation (PFA) may...
BACKGROUND
Phrenic nerve palsy is a well-known complication of cardiac ablation, resulting from the application of direct thermal energy. Emerging pulsed field ablation (PFA) may reduce the risk of phrenic nerve injury but has not been well characterized.
METHODS
Accelerometers and continuous pacing were used during PFA deliveries in a porcine model. Acute dose response was established in a first experimental phase with ascending PFA intensity delivered to the phrenic nerve (n=12). In a second phase, nerves were targeted with a single ablation level to observe the effect of repetitive ablations on nerve function (n=4). A third chronic phase characterized assessed histopathology of nerves adjacent to ablated cardiac tissue (n=6).
RESULTS
Acutely, we observed a dose-dependent response in phrenic nerve function including reversible stunning (R=0.965, <0.001). Furthermore, acute results demonstrated that phrenic nerve function responded to varying levels of PFA and catheter proximity placements, resulting in either: no effect, effect, or stunning. In the chronic study phase, successful isolation of superior vena cava at a dose not predicted to cause phrenic nerve dysfunction was associated with normal phrenic nerve function and normal phrenic nerve histopathology at 4 weeks.
CONCLUSIONS
Proximity of the catheter to the phrenic nerve and the PFA dose level were critical for phrenic nerve response. Gross and histopathologic evaluation of phrenic nerves and diaphragms at a chronic time point yielded no injury. These results provide a basis for understanding the susceptibility and recovery of phrenic nerves in response to PFA and a need for appropriate caution in moving beyond animal models.
Topics: Animals; Atrial Fibrillation; Catheter Ablation; Peripheral Nerve Injuries; Phrenic Nerve; Pulmonary Veins; Swine; Vena Cava, Superior
PubMed: 35649121
DOI: 10.1161/CIRCEP.121.010127 -
Scientific Reports Mar 2019Rotational thromboelastometry is recommended to guide haemostatic therapy in trauma-related coagulopathy. In the case of unsuccessful venepuncture, intraosseous access... (Comparative Study)
Comparative Study Observational Study
Rotational thromboelastometry is recommended to guide haemostatic therapy in trauma-related coagulopathy. In the case of unsuccessful venepuncture, intraosseous access allows immediate administration of drugs and volume replacement. Feasibility of rotational thromboelastometry from intraosseous blood has not yet been investigated in humans. We performed rotational thromboelastometry and standard coagulation assays from intraosseous and intravenous blood samples in 19 volunteers and 4 patients undergoing general anaesthesia. Intraosseous access was performed either at the tibial bone or the proximal humerus. We observed visible clotting in the majority of the intraosseous samples. Only 13% of the probes allowed realization of rotational thromboelastometry. ROTEM parameters are reported as follows: shorter median clotting time (CT) in EXTEM, INTEM, and APTEM (53 vs. 68 s; 140 vs. 154 s; 54 vs. 62.5 s) and smaller median maximal clot firmness (MCF) in EXTEM and APTEM (56 vs. 63 mm; 55 vs. 62 mm) in intraosseous samples. We found no relevant differences in median MCF values in FIBTEM and INTEM (12 vs. 13 mm; 60 vs. 59 mm). Given the difficulties we faced during IO blood sampling in a study setting, we advise against ROTEM measurements out of IO blood for guidance of procoagulant therapy in emergency situations.
Topics: Adolescent; Adult; Blood Coagulation; Case-Control Studies; Feasibility Studies; Female; Humans; Humerus; Male; Middle Aged; Thrombelastography; Tibia; Veins; Wounds and Injuries; Young Adult
PubMed: 30842625
DOI: 10.1038/s41598-019-40412-0 -
JAMA Surgery Feb 2018Since publication of the CRASH-2 and MATTERs studies, the US military has included tranexamic acid (TXA) in clinical practice guidelines. While TXA was shown to decrease...
IMPORTANCE
Since publication of the CRASH-2 and MATTERs studies, the US military has included tranexamic acid (TXA) in clinical practice guidelines. While TXA was shown to decrease mortality in trauma patients requiring massive transfusion, improper administration and increased risk of venous thromboembolism remain a concern.
OBJECTIVE
To determine the appropriateness of TXA administration by US military medical personnel based on current Joint Trauma System clinical practice guidelines and to determine if TXA administration is associated with venous thromboembolism.
DESIGN, SETTING, AND PARTICIPANTS
This cohort study of US military casualties in US military combat support hospitals in Afghanistan and a single US-based tertiary military treatment facility within the continental United States was conducted from 2011 to 2015, with follow-up through initial hospitalization and readmissions.
EXPOSURES
Data collected for all patients included demographic information as well as Injury Severity Score; receipt of blood products, TXA, and/or a massive transfusion; and admission hemodynamics.
MAIN OUTCOMES AND MEASURES
Variance from guidelines in TXA administration and venous thromboembolism. Tranexamic acid overuse was defined as a hemodynamically stable patient receiving TXA but not a massive transfusion, underuse was defined as a patient receiving a massive transfusion but not TXA, and TXA administration was considered delayed when given more than 3 hours after injury.
RESULTS
Of the 455 identified patients, 443 (97.4%) were male, and the mean (SD) age was 25.3 (4.8) years. A total of 173 patients (38.0%) received a massive transfusion, and 139 (30.5%) received TXA in theater. Overuse occurred in 18 of 282 patients (6.4%) and underuse in 46 of 173 (26.6%) receiving massive transfusions, and delayed administration was found in 6 of 145 patients (4.3%) receiving TXA. Overuse increased at 3.3% per quarter (95% CI, 4.0-9.9; P < .001; R2 = 0.340) and underuse decreased at -4.4% per quarter (95% CI, -4.5 to -3.6; P < .001; R2 = 0.410). Tranexamic acid administration was an independent risk factor for venous thromboembolism (odds ratio, 2.58; 95% CI, 1.20-5.56; P = .02).
CONCLUSIONS AND RELEVANCE
Military medical personnel decreased missed opportunities to appropriately use TXA but also increased overuse. In addition, TXA administration was an independent risk factor for venous thromboembolism. A reevaluation of the use of TXA in combat casualties should be undertaken.
Topics: Abdominal Injuries; Adult; Antifibrinolytic Agents; Blood Transfusion; Female; Guideline Adherence; Hemorrhage; Humans; Male; Medical Overuse; Military Personnel; Practice Guidelines as Topic; Retrospective Studies; Tranexamic Acid; United States; Venous Thromboembolism; Wounds and Injuries; Young Adult
PubMed: 29071337
DOI: 10.1001/jamasurg.2017.3821 -
Journal of Vascular Surgery. Venous and... May 2020Popliteal vascular injuries are common and frequently associated with limb loss. Although many studies have evaluated the treatment and outcomes of popliteal artery... (Comparative Study)
Comparative Study
BACKGROUND
Popliteal vascular injuries are common and frequently associated with limb loss. Although many studies have evaluated the treatment and outcomes of popliteal artery injuries (PAI), there is little available evidence regarding popliteal venous injuries (PVI). As such, substantial debate remains regarding the benefit of repair over ligation of PVI. The objectives of this study were to compare in-hospital outcomes of repair versus ligation of isolated PVI, as well as to determine nonvascular factors associated with worse outcomes.
METHODS
Patients in the National Trauma Databank from 2007 to 2014 with at least one PVI were evaluated. First, patients with concomitant PVI and PAI were compared with patients with isolated PVI. Second, outcomes were compared between ligation and repair of isolated PVI. To limit the impact of concomitant injuries and focus on the impact of venous injury management, we defined isolated PVI as cases without concomitant PAI and with Abbreviated Injury Scale severity score of less than 3 for all body regions other than lower extremity. Patients dead on arrival and those with less than 18 years of age were excluded. The primary outcomes were in-hospital mortality, amputation, and in-hospital amputation-free survival (AFS). Secondary outcomes included lower extremity compartment syndrome, fasciotomy, acute kidney injury, pulmonary embolism, deep venous thrombosis, and inferior vena cava filter placement.
RESULTS
Overall, 1819 patients (0.03%) had a PVI and after exclusion 1213 met the criteria for initial analysis. Of those, 308 had isolated PVI, and 905 had combined PVI and PAI. Patients with combined PVI and PAI had higher rates of amputation (15.2% vs 6.8%; P < .001), fasciotomy (64.5% vs 30.8%; P < .001), compartment syndrome (14.8% vs 8.8%; P = .006), and a lower AFS (82.9% vs 91.8%; P < .001) than patients with isolated PVI. There was no difference in in-hospital mortality, amputation, or in-hospital AFS between ligation and repair of isolated PVI. On multivariable logistic regression of isolated PVI, ligation was not independently associated with in-hospital AFS, amputation, or mortality.
CONCLUSIONS
Ligation of isolated PVI was not an independent predictor of in-hospital mortality, lower extremity amputation, or in-hospital AFS. Ligation also did not result in higher rates of fasciotomy, acute kidney injury, or pulmonary embolism.
Topics: Adult; Amputation, Surgical; Databases, Factual; Female; Hospital Mortality; Humans; Ligation; Limb Salvage; Male; Middle Aged; Popliteal Vein; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; United States; Vascular Surgical Procedures; Vascular System Injuries; Young Adult
PubMed: 31843477
DOI: 10.1016/j.jvsv.2019.09.014 -
PloS One 2016We investigated the associations between the self-evaluated pain status and two pain biomarker candidates, nerve growth factor and S100A8/A9, in exudate from venous leg... (Observational Study)
Observational Study
We investigated the associations between the self-evaluated pain status and two pain biomarker candidates, nerve growth factor and S100A8/A9, in exudate from venous leg ulcer to finally develop an objective pain evaluation method. Patients with venous leg ulcer participated in this cross-sectional observational study conducted between April and October 2014 at two medical facilities. During routine wound care, each participant self-evaluated their pain status at each examination using the 10-point numerical rating scale (present pain intensity) and the short-form McGill Pain Questionnaire 2 (continuous pain, intermittent pain, neuropathic pain, affective descriptors, and total score). Venous leg ulcer exudate sample was collected after wound cleansing. The nerve growth factor and S100A8/A9 concentrations in the venous leg ulcer exudate were measured by enzyme-linked immunosorbent assay and standardized according to the wound area. The association between each pain status and the two standardized protein concentrations was evaluated using Spearman's correlation coefficient. In 30 sample collected from 13 participants, the standardized nerve growth factor concentration was negatively correlated with continuous pain (ρ = -0.47, P = 0.01), intermittent pain (ρ = -0.48, P = 0.01), neuropathic pain (ρ = -0.51, P = 0.01), and total score (ρ = -0.46, P = 0.01). The standardized S100A8/A9 concentration was positively correlated with present pain intensity (ρ = 0.46, P = 0.03) and continuous pain (ρ = 0.48, P = 0.03). Thus, these two proteins may be useful for objective evaluation of wound pain in venous leg ulcer patients.
Topics: Adult; Aged; Aged, 80 and over; Calgranulin A; Calgranulin B; Cross-Sectional Studies; Enzyme-Linked Immunosorbent Assay; Exudates and Transudates; Female; Humans; Male; Middle Aged; Nerve Growth Factor; Pain; Pain Measurement; Pilot Projects; Surveys and Questionnaires; Varicose Ulcer; Wound Healing; Wounds and Injuries
PubMed: 27936243
DOI: 10.1371/journal.pone.0167478 -
Journal of Neurotrauma Jan 2019Treatment of severe traumatic brain injury (TBI) in the intensive care unit focuses on controlling intracranial pressure, ensuring sufficient cerebral perfusion, and... (Comparative Study)
Comparative Study Observational Study
Treatment of severe traumatic brain injury (TBI) in the intensive care unit focuses on controlling intracranial pressure, ensuring sufficient cerebral perfusion, and monitoring for secondary injuries. However, there are limited prognostic tools and no biomarkers or tests of the evolving neuropathology. Metabolomics has the potential to be a powerful tool to indirectly monitor evolving dysfunctional metabolism. We compared metabolite levels in simultaneously collected arterial and jugular venous samples in acute TBI patients undergoing intensive care as well as in healthy control volunteers. Our results show that, first, many circulating metabolites are decreased in TBI patients compared with healthy controls days after injury; both proline and hydroxyproline were depleted by ≥60% compared with healthy controls, as was gluconate. Second, both arterial and jugular venous plasma metabolomic analysis separates TBI patients from healthy controls and shows that distinct combinations of metabolites are driving the group separation in the two blood types. Third, TBI patients under heavy sedation with pentobarbital at the time of blood collection were discernibly different from patients not receiving pentobarbital. These results highlight the importance of accounting for medications in metabolomics analysis. Jugular venous plasma metabolomics shows potential as a minimally invasive tool to identify and study dysfunctional cerebral metabolism after TBI.
Topics: Adolescent; Adult; Aged; Biomarkers; Brain Injuries, Traumatic; Cohort Studies; Female; Humans; Hypnotics and Sedatives; Jugular Veins; Male; Metabolomics; Middle Aged; Pentobarbital; Young Adult
PubMed: 29901425
DOI: 10.1089/neu.2018.5674