Landy P. Paolella

Antibiotics and Nephrostomy Tube Care: Preliminary Observations Part II. Bacteremia

Bacteriuria occurs after long-term drainage of the kidney. This study was designed to determine if the risk of bacteremia increases at the time of tube or stent change, whether bacteremia correlates with clinical infection, and if prophylactic antibiotics are effective in the prevention of bacteremia. One hundred four tube changes in 74 patients with percutaneous nephrostomy tubes and documented positive urine cultures were studied. Patients were arbitrarily divided into groups receiving and not receiving antibiotics before nephrostomy tube change. Asymptomatic bacteremia was documented in 11 of 104 tube changes (11%). Results of five blood cultures were positive in the group receiving antibiotics, and six cases of bacteremia occurred in the group not receiving antibiotics (P = .96). Routine nephrostomy/stent change can cause frequent, asymptomatic bacteremia in patients with colonization of bacteria in the urinary tract. Antibiotic prophylaxis was unsuccessful in preventing transient bacteremia, a factor that may have implications in patients with underlying valvular heart disease and other patients at risk for bacteremia.

Topographic location of the left atrium by computed tomography: reducing pulmonary artery catheter calibration error.

Two potential errors of pulmonary artery wedge pressure measurement that have received little attention are improper anatomic referencing of the transducer and nondependent placement of the pulmonary artery catheter tip. Transducers are often referenced to the midaxillary line of the supine patient. We utilized CT of the chest to determine accurately the topographic location of the left atrium to evaluate the accuracy of referencing the transducer in this position and to investigate atrial location in the lateral decubitus positions vis-à-vis external landmarks, so that more accurate referencing could be performed with a pulmonary artery catheter tip in the dependent lung. A prospective group consisting of ten patients referred for chest CT as well as retrospective review of 40 chest CT scans served as the study population. This study demonstrated a discrepancy between the perceived midaxillary line and the true location of the midleft atrium. Lateral decubitus CT scanning revealed a more readily localizable surface anatomic landmark which consistently and accurately predicts midleft atrial location. In addition, the appropriate decubitus position guarantees dependent catheter tip placement (Zone 3).

Percutaneous alternatives in nutritional support: a radiologic perspective

As alternatives to per os feeding and nutritional support increase in number and complexity, the interventional radiologist has come to play a more significant role in the creation and maintenance of nutritional access. In very difficult access cases, the concerted effort of the nutritional surgeon and the radiologist is often required. We describe several such situations which have been successfully managed at our institution. The indications for and techniques of percutaneous reestablishment of surgically placed jejunostomy tubes, the percutaneous conversion of gastrostomy to jejunostomy tubes with retention of the gastrostomy tube, and percutaneous placement of an inferior vena caval Hickman catheter are all described in detail.

Extensive Thromboembolic Disease of the Hand and Forearm: Treatment with Thrombolytic Therapy

Six patients with extensive hand and forearm thromboembolic disease were treated by means of intraarterial infusion of urokinase, with good clinical results. Four significant complications occurred, including a possible stroke. Embolization of pericatheter thrombus was a possible etiologic factor in this case. Antegrade brachial artery puncture should be used in the setting of prolonged upper extremity thrombolytic therapy to avoid the cerebral vasculature. Thrombolysis is an effective technique for tissue salvage in cases of inoperable hand thrombosis.

Arterial rupture without balloon rupture during percutaneous transluminal angioplasty

A 58-year-old man with severe left lower extremity claudication and rest pain underwent percutaneous transluminal angioplasty. A high-pressure balloon was inflated in an area of severe atherosclerotic narrowing. The patient complained of severe pain during inflation and had a vasovagal response. After balloon deflation, angiography displayed extravasation just inferior to the lower edge of the balloon. Immediate inflation of the balloon tamponaded the leak and allowed the patients transfer to the operating room in stable condition. It is hypothesized that the new high-pressure balloons can overcome resistance in nondistensible arterial walls, causing rupture without balloon rupture.