Wan-Ching Lien

Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation

OBJECTIVES This study aimed to assess the diagnostic accuracy and timeliness of using tracheal ultrasound to examine endotracheal tube placement during emergency intubation. METHODS This was a prospective, observational study, conducted at the emergency department of a national university teaching hospital. Patients received emergency intubation because of impending respiratory failure, cardiac arrest, or severe trauma. The tracheal rapid ultrasound exam (T.R.U.E.) was performed during emergency intubation with the transducer placed transversely at the trachea over the suprasternal notch. Quantitative waveform capnography was used as the criterion standard for confirmation of tracheal intubation. The main outcome was the concordance between the T.R.U.E. and the capnography. RESULTS A total of 112 patients were included in the analysis, and 17 (15.2%) had esophageal intubations. The overall accuracy of the T.R.U.E. was 98.2% (95% confidence interval [CI]: 93.7-99.5%). The kappa (κ) value was 0.93 (95% CI: 0.84-1.00), indicating a high degree of agreement between the T.R.U.E. and capnography. The sensitivity, specificity, positive predictive value, and negative predictive value of the T.R.U.E. were 98.9% (95% CI: 94.3-99.8%), 94.1% (95% CI: 73.0-99.0%), 98.9% (95% CI: 94.3-99.8%) and 94.1% (95% CI: 73.0-99.0%). The median operating time of the T.R.U.E. was 9.0s (interquartile range [IQR]: 6.0, 14.0). CONCLUSIONS The application of the T.R.U.E. to examine endotracheal tube placement during emergency intubation is feasible, and can be rapidly performed.

Real-time tracheal ultrasonography for confirmation of endotracheal tube placement during cardiopulmonary resuscitation

OBJECTIVE This study aimed to evaluate the accuracy of tracheal ultrasonography for assessing endotracheal tube position during cardiopulmonary resuscitation (CPR). METHODS We performed a prospective observational study of patients undergoing emergency intubation during CPR. Real-time tracheal ultrasonography was performed during the intubation with the transducer placed transversely just above the suprasternal notch, to assess for endotracheal tube positioning and exclude esophageal intubation. The position of trachea was identified by a hyperechoic air-mucosa (A-M) interface with posterior reverberation artifact (comet-tail artifact). The endotracheal tube position was defined as endotracheal if single A-M interface with comet-tail artifact was observed. Endotracheal tube position was defined as intraesophageal if a second A-M interface appeared, suggesting a false second airway (double tract sign). The gold standard of correct endotracheal intubation was the combination of clinical auscultation and quantitative waveform capnography. The main outcome was the accuracy of tracheal ultrasonography in assessing endotracheal tube position during CPR. RESULTS Among the 89 patients enrolled, 7 (7.8%) had esophageal intubations. The sensitivity, specificity, positive predictive value, and negative predictive value of tracheal ultrasonography were 100% (95% confidence interval [CI]: 94.4-100%), 85.7% (95% CI: 42.0-99.2%), 98.8% (95% CI: 92.5-99.0%) and 100% (95% CI: 54.7-100%), respectively. Positive and negative likelihood ratios were 7.0 (95% CI: 1.1-43.0) and 0.0, respectively. CONCLUSIONS Real-time tracheal ultrasonography is an accurate method for identifying endotracheal tube position during CPR without the need for interruption of chest compression. Tracheal ultrasonography in resuscitation management may serve as a powerful adjunct in trained hands.

Ultrasonographic lung sliding sign in confirming proper endotracheal intubation during emergency intubation.

AIM OF STUDY Unrecognized one-lung intubations (also known as main-stem intubation) can lead to hypoventilation, atelectasis, barotrauma, and even patient death. Many traditional methods can be employed to detect one-lung intubation; however, each of these methods has limitations and is not consistently reliable in emergency settings. This study aimed to assess the accuracy and timeliness of ultrasound to confirm proper endotracheal intubation. METHODS This was a prospective, single-center, observational study conducted at the emergency department of a national university teaching hospital. Patients received emergency tracheal intubation because of respiratory failure or cardiac arrest. After intubation, bedside ultrasound was performed with a transducer placed on the chest bilaterally at the mid-axillary line, to identify lung sliding over the lungs bilaterally during ventilation. Chest radiography was used as the criterion standard for confirmation of endotracheal tube position. RESULTS One hundred and fifteen patients needing tracheal intubation were included, and nine (7.8%) had one-lung intubations. The overall accuracy of ultrasound to confirm proper endotracheal intubation was 88.7% (95% confidence interval (CI): 81.6-93.3%). The positive predictive value was 94.7% (95% CI: 87.1-97.9%) in the non-cardiac-arrest group and 100% (95% CI: 87.1-100.0%) in the cardiac-arrest group. The median operating time of ultrasound was 88 s (interquartile range [IQR]: 55.0, 193.0), and of chest radiography was 1349 s (IQR: 879.0, 2221.0) post intubation. CONCLUSIONS In this study, the positive predictive value of bilateral lung sliding in confirming proper endotracheal intubation was high, especially among patients with cardiac arrest. Considerable time advantage of ultrasound over chest radiography was demonstrated.

Male gender and renal dysfunction are predictors of adverse outcome in nonpostoperative ischemic colitis patients.

Objective Ischemic colitis (IC) spans a broad spectrum from self-limiting illness to intestinal gangrene and mortality. Prognostic factors specifically for nonpostoperative IC were not fully characterized. We aim to focus on nonpostoperative IC in patients with renal dysfunction and try to identify prognostic factors for adverse outcomes. Methods We conducted a retrospective analysis at a university-affiliated tertiary medical center in Taiwan. From January 2003 to August 2008, 25 men and 52 women (mean age: 66 y) had colonoscopic biopsy-proven IC without prior culprit surgery. We estimated glomerular filtration rate with simplified Modification of Diet in Renal Disease equation. Nine patients with glomerular filtration rate below 30 mL per minute per 1.73 m2 were classified as renal dysfunction group (including 7 dialysis patients). Adverse outcomes were defined as need for surgery and mortality. Predictors for adverse outcomes were captured by univariate and multivariate analysis. Research ethical committee approved the study protocol. Results Patients with renal dysfunction more often had: diabetes mellitus (56% vs. 16%, P=0.02), prolonged symptoms (6.8 d vs. 3.5 d, P=0.01), lower hemoglobin (11.1 g/dL vs. 13.4 g/dL, P=0.01), and more often right colonic involvement (56% vs. 19%, P=0.03). Renal dysfunction patients also had longer hospitalization days (median 15 d vs. 4 d, P=0.045). However, there was no statistical significance in the rate of either surgery or mortality between these 2 groups (P>0.05). Univariate analysis showed that renal dysfunction, sex, emergency department referral, presentation with abdominal pain were significant for adverse outcome (P<0.1). Multivariate analysis revealed that male sex conveyed 9.5-fold risk (P=0.01) and renal dysfunction conveyed 8.5-fold risk (P=0.03) for adverse outcomes. Conclusions Nonpostoperative IC patients with concurrent renal dysfunction had distinct clinical profiles. Multivariate analysis showed that male patients had 9.5-fold and renal dysfunction patients had 8.5-fold increased risk for adverse outcomes. Although IC is often self-limited, our data warrants special attention and aggressive therapy in treating these patients.

Long-Term Outcomes of Patients with Acute Cholecystitis after Successful Percutaneous Cholecystostomy Treatment and the Risk Factors for Recurrence: A Decade Experience at a Single Center

Background Percutaneous cholecystostomy tube (PCT) has been effectively used for the treatment of acute cholecystitis (AC) for patients unsuitable for early cholecystectomy. This retrospective study investigated the recurrence rate after successful PCT treatment and factors associated with recurrence. Methods We reviewed patients treated with PCT for AC from October 2004 through December 2013. Patients with successful PCT treatment were those who were free from persistent PCT drainage. We used multivariable logistic regression analysis sequentially to identify factors associated with each outcome. Results The study included 184 patients (mean age: 70.1 years). The average duration for parenteral antibiotics was 14.4 days and 20.0 days for PCT drainage. The one-year recurrence rate was 9.2% (17/184) with most recurrences occurring within two months (6.5%, 12/184) of the procedure. Complicated cholecystitis (odds ratio [OR]: 4.67; 95% confidence interval [CI]: 1.44–15.70; P = 0.01) and PCT drainage duration >32 days (OR: 4.92; 95% CI: 1.03–23.53; P = 0.05) positively correlated with one-year recurrence; parenteral antibiotics duration >10 days (OR: 0.21; 95% CI: 0.05–0.68; P = 0.01) was inversely associated with one-year recurrence. Conclusions The recurrence rate was low for patients after successful PCT treatment. Predictors for recurrence included the severity of initial AC and subsequently provided treatments.

Spontaneous rupture of an ovarian artery aneurysm.

Spontaneous rupture of an ovarian artery aneurysm is rare and is thought to be related to pregnancy or uterine fibroids. A patient without fibroids presented with extreme pain during normal menstruation. Ruptured ovarian artery aneurysm should be suspected in a multiparous woman with flank or abdominal pain and peritoneal signs.

Primary appendiceal adenocarcinoma with cecocolic intussusception.

1 Suzuki J, Yamauchi Y, Horikawa M, Yamagata S. Fasting therapy for psychosomatic diseases with special reference to its indication and therapeutic mechanism. Tohoku J. Exp. Med. 1976; 118 (Suppl.): 245– 59. 2 Fukudo S, Nomura T, Hongo M. Impact of corticotropin-releasing hormone on gastrointestinal motility and adrenocorticotropic hormone in normal controls and patients with irritable bowel syndrome. Gut 1998; 42 : 845–9. 3 Chadwick VS, Chen W, Shu D et al. Activation of the mucosal immune system in irritable bowel syndrome. Gastroenterology 2002; 122 : 1778–83. 4 Yamamoto H, Suzuki J, Yamauchi Y. Psychophysiological study on fasting therapy. Psychother. Psychosom. 1997; 32 : 229–40. 5 Mertz H, Morgan V, Tanner G et al. Regional cerebral activation in irritable bowel syndrome and control subjects with painful and nonpainful rectal distention. Gastroenterology 2000; 118 : 842–8. Figure 1 Small intestinal manometory at night (a) before and (b) after fasting therapy (FT). D1, duodenal bulb; D2, proximal second portion of the duodenal; D3, distal second portion of the duodenum. Intestinal dysmotility before FT improved after FT. Intestinal response to injection of neostigmine (16 μ g/kg) (c) before and (d) after FT. D1, duodenal bulb; D2, proximal second portion of the duodenal; D3, distal second portion of the duodenum; DC, descending colon; pH, duodenal pH; R, respiration; SC1, proximal sigmoid colon; SC2, mid sigmoid colon. In the colonic mucosa the mild infiltration with lymphocytes (e) before FT had returned to almost normal after FT (f). (a)

Bilateral psoas abscess formation after acupuncture.

peutic responsiveness or delayed resolution may easily lead to unnecessary diagnostic work. Moreover, round pneumonia can, occasionally, be difficult to distinguish from bronchogenic carcinoma. In adults, malignancy is the most frequent cause of pulmonary round or “coin” lesions. However, a trial of appropriate antibiotic therapy followed by a second chest radiograph should be considered in all patients with a pulmonary round lesion, because round pneumonia can appear at any age, and may be clinically silent. In this clinical setting, the presence of risk factors for malignancy, few or no symptoms, and older age frequently lead to a high suspicion of neoplasm. Thus, a prompt appreciation of the infectious nature of the lesion results in a cost-efficient strategy, obviating an unnecessary, expensive, and invasive evaluation for malignancy (5).

Isolated traumatic pancreatic rupture.

Traumatic pancreatic rupture is associated with high morbidity and mortality. The diagnosis is difficult and usually accompanied with other injuries. We reported a 17-year-old adolescent boy who experienced this disease alone. The diagnosis was first suspected in ultrasonography and then confirmed by computed tomography. Endoscopic retrograde pancreatography showed his pancreatic duct was patent. He made an uneventful recovery after 10 days of hospitalization. Ultrasonography is well known for detecting the presence of hemoperitoneum in blunt abdominal trauma. Furthermore, it can be applied to the assessment of patients with posttraumatic abdominal pain. It provides a real-time, noninvasive, and inexpensive means for screening this kind of patients.

Early detection of Blunt traumatic brachial artery pseudoaneurysm by point of care ultrasound: case report

Patient and method A 61-year-old man with hypertension history, presented with progressive left elbow pain and swelling after blunt injury. He was fell down 1 week ago and direct contusion to his arm. He reported no numbness or weakness. His vital signs were stable except high blood pressure (188/108mHg) Physical examination revealed ecchymosis of his arm (Figure 1) and palpable pulsation over brachial, radial and ulnar artery. Laboratory exam showed elevatingCK(793 IU/L) otherwise normal. X-ray exam revealed normal. US revealed an anechoiclesion over elbow with pulsation.(Figures 2 and 3) and some heterogenic lesion over muscle layer, PA and hematoma were considered. CTA of extremity showed PA of brachial artery.(Figures 4 and 5) Patient received endografting and fasciotomy, patient was discharged smoothly after 10 days admission.