Mark L. Blas

A randomized study of left versus right internal jugular vein cannulation in adults

STUDY OBJECTIVE To compare the success rate and incidence of complications of right internal jugular vein (RIJV) versus left internal jugular vein (LIJV) cannulation using external landmarks or surface ultrasound guidance. DESIGN Prospective randomized study. SETTING Operating room of a university-affiliated hospital. PATIENTS 120 adult patients scheduled for elective abdominal, vascular, or cardiothoracic procedures with general anesthesia and mechanical ventilation in whom central venous cannulation was clinically indicated. INTERVENTIONS Patients were randomized to four groups for RIJV cannulation using the landmark approach (Group 1) or surface ultrasound (Group 2) versus LIJV cannulation with the landmark approach (Group 3) or ultrasound (Group 4). MEASUREMENTS AND MAIN RESULTS The data collected included time from first puncture to guidewire insertion, number of attempts, and associated complications. If conversion to the ultrasound technique was required, the number of crossover patients and reasons for failure were recorded. Cannulation of the LIJV was more time consuming; it required more attempts; and it was associated with a greater number of complications when compared to the right side (p < 0.05). CONCLUSIONS Left IJV cannulation is more time consuming than RIJV cannulation and is associated with a higher incidence of complications. The use of ultrasound improves success rate and decreases the number of complications during IJV cannulation.

Bacitracin irrigation: a cause of anaphylaxis in the operating room.

Implications We report a unique case of acute anaphylaxis after mediastinal irrigation with a dilute bacitracin solution.

Inhibition of phosphodiesterase type III before aortic cross-clamping preserves intramyocardial cyclic adenosine monophosphate during cardiopulmonary bypass.

Inotropes are often used to treat myocardial dysfunction shortly after cardiopulmonary bypass (CPB). &bgr;-Adrenergic agonists improve contractility, in part by increasing cyclic adenosine monophosphate (cAMP) production, whereas phosphodiesterase type III inhibitors prevent its breakdown. CPB is associated with abnormalities at the &bgr;-receptor level and diminished adenyl cyclase activity, both of which tend to decrease cAMP. These effects may be increased in the presence of preexisting myocardial dysfunction. We tested the hypothesis that inhibition of phosphodiesterase type III before global myocardial ischemia and pharmacologic arrest results in the preservation of intramyocardial cAMP concentration during CPB. Twenty adult patients undergoing coronary artery bypass grafting with CPB were studied. After CPB was instituted, a myocardial biopsy was obtained from the apex of the left ventricle. Patients were randomized to receive either placebo or milrinone (50 &mgr;g/kg) through the bypass pump 10 min before aortic cross-clamping. Another myocardial biopsy was performed adjacent to the left ventricular apex just before weaning from CPB. Myocardial cAMP concentration was determined by radioimmunoassay. Myocyte protein content was determined by the Bradford method by using a commercial kit. There were no significant demographic differences between the groups; however, patients in the Milrinone group had a lower left ventricular ejection fraction than placebo (41% ± 13% vs 53% ± 7%;P < 0.05). Patients who received milrinone had larger cAMP concentrations at the end of CPB compared with placebo (21 ± 12.5 pmol/mg protein versus 12.8 ± 2.2 pmol/mg protein;P < 0.05). The administration of milrinone before aortic cross-clamping is associated with increased intramyocardial cAMP concentration at the end of CPB.

Use of near-infrared spectroscopy to monitor cerebral oxygenation during coronary artery bypass surgery in a patient with bilateral internal carotid artery occlusion

R EGIONAL CEREBRAL OXYGEN SATURATION (RSO2) depends on the balance between regional oxygen delivery and consumption. The factors that alter this relationship include global and regional cerebral blood flow, hemoglobin concentration, arterial oxygen saturation, and regional cerebral oxygen consumption. Near-infrared spectroscopy (NIRS) is a novel method used to determine RSO2 .1 This technique has been used predominantly in infants and children to determine cerebral oxygenation during extracorporeal membrane oxygenation. 2 Its application has been expanded for use during carotid endarterectomy and in operations involving cardiopulmonary bypass (CPB). 3,4 By providing continuous RSO2 monitoring, this technique may allow detection of changes that signal early cerebral hypoxia and thus allow for prompt therapeutic intervention to minimize risk of neurologic injury. This case report describes the use of continuous cerebral oximetry during coronary artery bypass graft (CABG) surgery in a patient with bilateral internal carotid artery occlusion.