Janice Newsome

Understanding patient preferences for femoral central venous catheterization among patients with sickle cell disease

A temporary large-bore central venous catheter (CVC) is placed in patients with sickle cell disease (SCD) to facilitate red blood cell exchange apheresis in order to treat or prevent hemoglobin S-associated complications (1). It has been our observation that some patients strongly prefer the common femoral vein to the internal jugular vein for CVC placement. Limited data exist in the literature on factors that could explain this observation. We aim to explore patient preferences for femoral central venous catheterization among patients with SCD and assess the perceived importance of factors affecting their preferences. From January 2011 to February 2016, 163 consecutive patients underwent a total of 753 procedures of temporary CVC placement at our institution (39% of CVCs placed in the common femoral vein, 59% in the internal jugular vein, and 2% in other sites). The mean age was 34 years (range, 18-69 years). Ninety-two (63%) were females and 53 (37%) were males. We conducted a retrospective survey via telephone interview asking whether they had preferences for the femoral vein versus the internal jugular vein. They rated the importance of various factors in their decisions on a scale of 1 (no importance) to 5 (greatest importance). Logistic regression analysis was performed to evaluate independent clinicodemographic factors associated with preferences. Of the 145 respondents (89% response rate), 42 (29%) reported preferences for the femoral vein. They indicated that the most important factor was concern about possible scar formation at the site of catheterization (mean rating, 4.4). In multivariate analysis, female sex (p<0.001) and known occlusion in the internal jugular vein (p = 0.009) were associated with preferences for femoral central venous catheterization (Tab. I). Patients voiced substantial concerns over scar formation in the neck area if they were to undergo catheter placement in the internal jugular vein. Many sickle cell patients have to undergo multiple repeat procedures of CVC placement whenever needed for red cell exchange apheresis. Taking this into account, scar formation remains a big concern in this young population. Several previous studies reported that femoral central venous catheterization has higher rates of complications such as catheter-related infections and thrombosis with hazard ratios of 2.8-4.2 when compared to internal jugular catheterization (2-5). Despite our on-going, constant efforts to understand patients’ perspectives and educate them on pertinent risks and benefits related to central venous catheterization, some patients still remain poorly informed of potential risks of their preferences. It is our belief that although patient preferences are important, they should be based on well-informed decisions. In conclusion, adult female patients with sickle cell disease often express a preference for the common femoral vein as a placement site of temporary large-bore central venous catheters, with concern about scar formation in the neck being reported as the most important factor. Future studies would be useful in evaluating complications associated with temporary femoral CVC placement in this patient population, and quality improvement studies can be also pursued to optimize patient engagement in shared decision making.

Atlas table: a dynamic innovative support device for the coming obesity epidemic

With obesity rates increasing rapidly, the Atlas table, a modular table overlay, was developed to address the unmet medical need of the inability of current interventional tables to support patients weighing more than 450 lbs. Current procedural tables have a posted weight limit of 500 lbs. In practice, this limit is 450 lbs due to the permanent installation of a 50 lb dye injector at the foot of the table. Instability is reported in patients in the range of 250–450 lbs, resulting in the need to modify how the table is placed over the base. Additional weight and mobility limitations exist due to the cantilever beam design of the existing table that allows movement of the C-arm fluoroscope to move around the entire table. A clinical device should bear all of the weight of an 800 lb patient, without failing during emergency chest compressions, which makes the weight capacity necessary 1200 lbs. This must be accomplished without obstructing the movement of the C-arm of the existing table or requiring a more than 2% increase in radiation. Our table overlay design features a lightweight, radiolucent tabletop and four modular height-adjusting legs that move with the existing table and do not require separate controls. The legs clamp to the radiolucent tabletop securely but not permanently so that they can be moved when needed, with buttons that swing out and cause the table to raise or lower by being trigger by contact from the existing table. The proposed design safely holds and lifts 1200 lbs.

Percutaneous manipulation on intracardiac catheters: Retrieval, unknotting, repositioning and stripping

Puroose:Intracardiac embolization of catheter fragments,andiatrogenic,and other foreign bodies,such as stents,intracardiacformation of knots in catheters,malpositioning of intracardiaccatheters,and thrombi formation in intracardiac catheters arc seriouscomplications of catbeterization techniques,associated with highmorbidity and mortality.Material and Metbods:We performed percutaneous retrieval ofintracardiac catheters and iatrogenic foreign bodies(n=40),unknottingof catheter knots(n=4),repositioning of malpositioned catheters(n=31),and stripping of catheters(n=25),in 100 adults and children.Interveotional equipment used included:retrieval baskets,retrievalwire loops,deflector wires,retrieval forceps,and differentangiographic catheters,alone or in combination.Results:Retrieval of catheter fragments and iatrogenic foreign bodieswas successful in 38 patients.There were 3 failures:an IVC filter,acatheter,ans a Wallstent,lodged in the right atrium.Unknotting ofcatheter knots,repositioning of misplaced catheters,and stripping ofcatheters was successful in all patients.There were no majorcomplications.Minor complications were infrequent.Cinclusions:These procedures are quick,safe,and effective tomanage potentially serious complications of percutaneouscatheterization techniques.Dialysis and other central catheters andports can be functional for longer periods.A major operation to solvethese problems,which may include open heart surgery,is avoided.