Claudia Schummer

Is Traditional Reading of the Bedside Chest Radiograph Appropriate To Detect Intraatrial Central Venous Catheter Position

BACKGROUND Traditionally, the positioning of central venous catheters (CVCs) outside the right atrium (RA) in patients receiving intensive care is determined by surrogate landmarks on bedside chest radiographs (CXRs). The validity of this method was examined by comparing readings of radiologists with the results of transesophageal echocardiography (TEE). METHODS Prospective study at university hospital. Two hundred thirteen adults scheduled for cardiothoracic surgery were randomized to right or left internal jugular vein catheterization under ECG guidance. One senior radiologist and two radiologists in training independently read the CXRs, and determined whether the CVC tip ended in the RA and measured the vertical distance from the CVC tip to the carina (TC-distance). RESULTS Two hundred twelve CVC tips could be identified by TEE. Only left-sided CVCs (n = 5) ended in the upper RA (2.4%). Three of those patients were shorter than 160 cm. Specificity was 94% for senior radiologist, 44% for the first radiologist in training, and 60% for the second radiologist in training. The TC-distance of intraatrial catheters was 39, 55, 59, 80, and 83 mm, respectively. Thus, a TC-distance < or = 55 mm ensured extraatrial tip position in four of five intraatrial CVCs (80%, p = 0.002). The TC-distance of extraatrial catheters ranged from - 26 to 102 mm. CONCLUSIONS Reading of a bedside CXR alone is not very accurate to identify intraatrial CVC tip position. TC-distance is a helpful marker, and its specificity is as good as that of an experienced radiologist if a cutoff value of 55 mm is chosen.

The Pivotal Role of Vasopressin in Refractory Anaphylactic Shock

BACKGROUND: Severe anaphylaxis can be associated with cardiovascular collapse that is difficult to manage and does not respond to treatment with epinephrine. Because anaphylaxis is uncommon, unpredictable and may be fatal, a prospective, randomized, controlled trial in humans on the best management is difficult and guidelines are based on theory and anecdotes only. METHODS AND RESULTS: We report six cases in which the use of vasopressin was successful in the treatment of anaphylactic shock. CONCLUSIONS: Standard treatment of anaphylactic shock, including discontinuation of the causative agent, administration of epinephrine, and infusion of IV fluids, did not stabilize cardiocirculatory function, and adding arginine vasopressors resulted in prompt hemodynamic stabilization.

ECG-guided central venous catheter positioning: does it detect the pericardial reflection rather than the right atrium?

Background and objective: Although electrocardiography (ECG) guidance of central venous catheters (CVCs) is traditionally thought to detect the entrance into the right atrium (RA), there is little evidence in the literature to confirm this. We previously observed a high incidence of left-sided CVCs abutting the wall of the superior vena cava (SVC), even when the catheters were advanced past the point of increased P-wave amplitude. Our hypothesis was that this ECG amplitude signal is actually detecting the pericardial reflection rather than the RA. The goal of the study was to position catheter tips under ECG guidance outside the RA. Methods: One-hundred central venous triple-lumen catheters inserted either via the right or the left internal jugular veins, respectively, were analysed in cardiac surgical patients. The position of the catheter tip was ascertained by ECG. Method A: A Seldinger guide-wire in the distal lumen served as exploring electrode, the respective insertion depth was recorded. Method B: The middle lumen (port opening 2.5 cm from the catheter tip, thus the catheter was advanced more towards the atrium) filled with a saline 10% fluid column served as the exploring electrode, and the insertion depth was recorded again. Descriptive data are given as mean ± standard deviation. Results: On average, the catheters were advanced by the expected 2 ± 0.3 cm using Method B beyond the initial insertion by Method A. All 100 CVCs were finally correctly positioned in the SVC and confirmed by transoesophageal echocardiography. When chest radiography was performed after surgery not a single catheter abutted the lateral wall of the SVC. Conclusion: Since both methods detected the same structure, and catheters placed by Method B did not result in intra-atrial CVC tip position, the first increase in P-wave amplitude does correspond to a structure in the SVC, most likely the pericardial reflection.

Extravasation injury in the perioperative setting.

Extravasation is an unintentional injection or leakage of fluid in the perivascular or subcutaneous space. Extravasation injury results from a combination of factors, including solution cytotoxicity, osmolality, vasoconstrictor properties, infusion pressure, regional anatomical peculiarities, and other patient factors. We reviewed the hospital files of patients who had sustained a significant extravasation injury in the perioperative setting at two German hospitals. These cases highlight the risk of devastating consequences from extravasation injury. Vasoactive drugs and hyperosmolar and concentrated electrolyte solutions are the predominant vesicants in the perioperative setting. Prompt and appropriate intervention is important for avoiding or minimizing extensive tissue injury.

The anterior jugular venous system: variability and clinical impact.

The anterior jugular venous system, with its interconnections to the subclavian and deep jugular veins, provides a collateral venous network across the midline of the neck area, which is especially important in unilateral occlusion of an innominate vein. We illustrate the variability of this system and its clinical impact on catheterization by three cases of landmark-guided central venous cannulation. Case 1: Cannulation of the left internal jugular vein with a central venous catheter and of the left innominate vein (LIV) with a pulmonary artery catheter resulted in correctly positioned catheter tips. However, these catheters were actually not placed in the innominate vein but coursed through the jugular venous arch. Case 2: Cannulation of the left subclavian vein was complicated by resistance of guidewire advancement at 13 cm. Occlusion of the LIV and enlargement of the jugular venous arch were present. Case 3: Insertion of a pulmonary artery catheter and a central venous catheter through the LIV. The pulmonary artery catheter was correctly placed. The tip of the central venous catheter was mistakenly positioned in the left anterior jugular vein. We describe the normal anatomy of the anterior jugular venous system and its role as a major collateral. Correct placement of central venous catheters may be possible via the anterior jugular venous system. Conversely, central venous catheters malpositioned in the anterior jugular vein can increase the risk for complications and should be removed.

Two cases of delayed diagnosis of postpartal streptococcal toxic shock syndrome

BACKGROUND: Puerperal sepsis due to group A beta-hemolytic streptococcal (GAS) toxic shock syndrome is associated with very high morbidity and mortality. Luckily it is now rare, but diagnosis is not always easy. This report demonstrates the problem of recognizing this disease, and summarizes the current knowledge on the pathomechanism and management of streptococcal toxic shock syndrome. CASE: Two cases of postpartum streptococcal toxic shock syndrome due to GAS are described. In both cases the correct diagnosis was delayed for several days. The first patient was sent home with the diagnosis of German measles; the second patient was transferred to our neurological intensive care unit with the diagnosis of meningitis. Both patients were admitted to the intensive care unit in profound shock, both developed multiple organ failure, and one patient died. CONCLUSIONS: GAS may produce virulence factors that cause host tissue pathology. Besides aggressive modern intensive care treatment, early diagnosis and correct choice of anti-streptococcal antibiotics are crucial. A possible adverse effect of non-steroidal anti-inflammatory agents requires confirmation in a multicenter study.

Perforation der V. cava superior bei unerkannter Stenose Fallbericht einer letalen Komplikation einer zentralvenösen Katheterisierung

ZusammenfassungWir berichten über eine Kavaperforation bei einer multimorbiden Patientin durch einen Dialysekatheter infolge unerkannter Stenose der V. cava superior. Ursächlich für die Stenose war offensichtlich die Irritation der Gefäßwand durch einen 2 Wochen lang liegenden linksseitigen Subklavia-Dialysekatheter. Anhand dieser Kasuistik wollen wir die hohe Stenoserate linksseitiger Dialysekatheter ins Bewusstsein rufen, die, wie in unserem Fall, bei einer 2. Dialysekatheteranlage Ursache einer letalen Gefäßperforation sein kann. Um Katheterfehllagen ausschließen zu können, müssen nach jeder – auch scheinbar unproblematischen – zentralvenösen Katheteranlage Lagekontrollen durchgeführt werden: entweder ein Röntgenbild der Thoraxorgane oder ein intraatriales EKG in Verbindung mit Funktionsprüfungen wie freier Blutrückfluss über alle Lumina, mittels einer Blutgasanalyse des aspirierten Bluts oder invasiver Druckmessung. Nur eine Kombination kann ausreichend Sicherheit geben, da jeder Test für sich allein seine Schwächen hat. Bei Dialysekathetern, insbesondere linksseitigen, fordern wir immer eine Röntgenaufnahme, um die Parallelität des distalen Katheteranteils mit der Längsachse der V. cava superior zu verifizieren. Beim geringsten Zweifel sollte zum Ausschluss einer Gefäßperforation Kontrastmittel über den Katheter injiziert werden. Bei Hinweis auf eine Gefäßperforation stellt die Computertomographie des Thorax mit Kontrastmittel den nächsten diagnostischen Schritt dar, alternativ bietet sich noch die Transösophageale Echokardiographie (TEE) an.AbstractWe report on a case of fatal perforation of the superior vena cava. The perforation occurred after catheterization of the left internal jugular vein with a hemodialysis catheter, due to an unrecognised stenosis of the superior vena cava. Vascular trauma induced by a previous, also left-sided, subclavian vein-hemodialysis catheter (in place for 14 days), seemed to be the most likely pathomechanism of the stenotic lesion. It should be emphasised that this is a frequent complication especially of left-sided dialysis catheters. In the case described a stenosis was complicated by a misdirected second hemodialysis catheter. Although being repositioned under fluoroscopic control via a guide wire, an extravasal placement occurred but was unrecognised. In order to rule out catheter misplacement, the position of every central venous catheter has to be controlled. Standard methods are either chest X-ray or right atrial electrocardiography. Additionally, confirmation of correct intravenous placement requires a combination of free venous backflow of all lumen and/or blood gas analysis or venous pressure monitoring. Only a combination of tests gives ample certainty as each test for itself has its pitfalls. After placement of hemodialysis catheters, in particular left-sided catheters, we demand chest X-ray in order to verify that the catheter runs parallel with the long axis of the superior vena cava. In doubtful cases the threshold for contrast-enhanced angiographic control of the catheter should be low. If a perforation by the catheter is suspected it should be ruled out by computed tomographic scanning or transesophageal echocardiography.

Ultrasound guidance for placement control of central venous catheterization. Survey of 802 anesthesia departments for 2007 in Germany

OBJECTIVES AND METHODS In 2007 a survey on the development of the current practice of using ultrasound to assist central venous catheter (CVC) placement was carried out in 802 departments of anesthesiology and intensive care medicine in hospitals with more than 200 beds in Germany. These data were compared to data from a survey in 2003. Additionally, data regarding control of CVC positioning were collected. RESULTS The response rate was 58%. In these 468 departments approximately 340,000 CVCs are placed annually and 317 departments have access to an ultrasound machine. Ultrasound guidance is used by 188 (40%) departments for central venous cannulation. Of these only 24 (12.7%) use ultrasound routinely and 114 (60.6%) use it when faced with a difficult cannulation. Approximately one-third of the users perform continuous ultrasound guidance for CVC placement. Equipment was not at disposal in 115 (41.1%) departments not using ultrasound for CVC placement did not possess the equipment and 93 (33.2%) did not consider ultrasound necessary. Positioning of CVCs was controlled either by electrocardiogram (ECG) guidance and/or chest radiograph in 92%. CONCLUSION In Germany placement of central venous catheters is still usually based on anatomical landmarks. However, compared to 2003, ultrasound guidance for CVC placement is gradually being introduced (40% compared to 19%). Given the well-documented advantages of ultrasound guidance compared to landmark based approaches for central venous cannulation, acquisition of this technology should belong to the training programme of an anesthesiologist.

Ultraschall und Lagekontrolle bei der Anlage zentraler Venenkatheter

OBJECTIVES AND METHODS In 2007 a survey on the development of the current practice of using ultrasound to assist central venous catheter (CVC) placement was carried out in 802 departments of anesthesiology and intensive care medicine in hospitals with more than 200 beds in Germany. These data were compared to data from a survey in 2003. Additionally, data regarding control of CVC positioning were collected. RESULTS The response rate was 58%. In these 468 departments approximately 340,000 CVCs are placed annually and 317 departments have access to an ultrasound machine. Ultrasound guidance is used by 188 (40%) departments for central venous cannulation. Of these only 24 (12.7%) use ultrasound routinely and 114 (60.6%) use it when faced with a difficult cannulation. Approximately one-third of the users perform continuous ultrasound guidance for CVC placement. Equipment was not at disposal in 115 (41.1%) departments not using ultrasound for CVC placement did not possess the equipment and 93 (33.2%) did not consider ultrasound necessary. Positioning of CVCs was controlled either by electrocardiogram (ECG) guidance and/or chest radiograph in 92%. CONCLUSION In Germany placement of central venous catheters is still usually based on anatomical landmarks. However, compared to 2003, ultrasound guidance for CVC placement is gradually being introduced (40% compared to 19%). Given the well-documented advantages of ultrasound guidance compared to landmark based approaches for central venous cannulation, acquisition of this technology should belong to the training programme of an anesthesiologist.

Persistent Left Superior Vena Cava: Clinical Implications for Central Venous Cannulation:

In general, persistence of the left superior vena cava (LSVC), the most common anomaly of the venous circulation, is asymptomatic. Diagnosis of a catheter in a persistent LSVC is not straight forward, and a LSVC can create difficulties during central venous and pulmonary artery catheterization. We discuss the differential diagnosis of left-sided central venous catheters (CVC). Finally a directive is given to prevent dilator-induced vessel injuries. We report the cannulation of an unsuspected persistent LSVC in two patients. A dilator-induced vessel injury contributed significantly to the fatal outcome in the first case. On a plain chest X-ray, a catheter in a LSVC will run down the left mediastinal border and can be confused with other intravascular malpositions and extravascular malpositions. Contrast-enhanced lateral chest radiograph is an inexpensive and readily available method that can be used to determine exact position.