Renal transplantation in patients with indwelling continuous ambulatory peritoneal dialysis catheters

Controversy exists regarding management of the continuous ambulatory peritoneal dialysis catheter in patients undergoing renal transplantation. We performed 30 transplants (23 cadaveric and 7 living related) in 27 patients with indwelling continuous ambulatory peritoneal dialysis catheters. Dialysis was necessary in the immediate post-transplantation period in 9 of 30 patients (30 per cent). Of these 9 patients 3 had temporary hemodialysis and 6 resumed continuous ambulatory peritoneal dialysis with the indwelling catheter. Two postoperative complications clearly were related to the continuous ambulatory peritoneal dialysis catheter: 1 patient required abdominal exploration for control of bleeding related to disruption of peritoneal adhesions at the time the continuous ambulatory peritoneal dialysis catheter was removed and 1 suffered an abscess at the catheter site 1 month after the catheter was removed. No patient experienced peritonitis during immunosuppression after transplantation. We support leaving the continuous ambulatory peritoneal dialysis catheter during and after transplantation to simplify pre-transplantation patient care and to avoid the possible need for temporary post-transplantation hemodialysis in many patients.     

Salvage of problematic peritoneal dialysis catheters

Peritoneal dialysis (PD) is a markedly underutilized modality for permanent renal replacement therapy in the United States owing to a low rate of patient referral and high rate of patient dropout or transfer to hemodialysis. One cause for patient loss from PD is problematic PD catheters that often are removed rather than being subjected to simple surgical salvage procedures. We report three patients with problematic catheters and our approach to their management. The first patient developed erosion of the skin overlying the portion of the catheter between the deep and superficial cuffs after 6 months of PD. The second patient developed extrusion of the superficial cuff after 4 years of PD. The third patient demonstrated a localized abscess at the incision site for catheter insertion after 3 years of PD. Other than a mild superficial exit site infection and localized abscess in the second and third patient, respectively, there were no associated infections of the catheter tunnel and cuff or of the peritoneal cavity as determined by either clinical examination, ultrasound evidence of fluid collection, or cultures and white blood cell counts. All three cases were managed successfully by interventional nephrology on an outpatient basis and under local anesthesia without either catheter removal or placement of a new PD catheter. It was possible to continue uninterrupted PD in the first and third patients, while the second patient had temporary hemodialysis to allow for complete healing of the surgical wound. We conclude that in selected cases simple interventions can salvage problematic PD catheters and maintain patients on PD.     

Use of a 23-gauge continuous spinal catheter for labor analgesia: a case series

Seven women received labor analgesia with 0.125% bupivacaine and fentanyl 2 μg/mL delivered through a new generation of over-the-needle 23-gauge spinal catheters. The first patient was managed with intermittent bolus injections but inadequate pain control prompted a conversion to a continuous infusion for subsequent patients. One patient developed a postdural puncture headache following catheterization for 5 h, but there were no headaches in those who had an indwelling catheter for 8 h or longer. In one patient the catheter was also used to provide anesthesia for cesarean delivery with 0.5% bupivacaine and fentanyl 20 μg. The largest drop in mean arterial blood pressure was 34% which occurred during the intermittent dosing period in the first patient. The mean blood pressure decrease was <25% in the remaining patients. One patient with labor lasting over 17 h developed pain and paresthesia that resolved in 24 h without treatment. Two patients had motor block that necessitated a temporary reduction in rate or discontinuation of the infusion. The continuous spinal catheter appeared to be acceptable to patients but the optimal choice of drugs, concentration, and mode of administration remains to be determined.     

Temporary use of an eroded bipolar pacemaker system

Over a 2.5-year period, of 176 bipolar pacemaker procedures, six were complicated by erosion (incidence, 3.4%). One patient was treated whose pacemaker was inserted at another hospital. Time from insertion to presentation ranged from 5 to 23 months. When infection was present, Staphylococcus epidermidis was found to be the offending organism. We have used a staged method for managing this problem. Initially, the bipolar pulse generator was exteriorized and worn suspended around the neck while infection was controlled. A new pacemaker system (catheter and pulse generator) was inserted from the opposite side once infection was controlled. The main advantage of this type of approach is that the old pacing catheter and old bipolar generator can be used as an effective temporary pacing system, while the infection is being controlled thus eliminating the step of inserting a temporary pacing catheter after the eroded generator and catheter have been removed. A temporary pacing catheter is only safe and effective for a few days (perhaps up to a week), and this may not be sufficient time to be sure that infection is locally controlled. In addition, the patient can be ambulatory as the old permanent catheter is not likely to be dislodged easily as compared with a temporary catheter. Follow up ranging from 2 to 23 months has shown this to be an effective method for treating bipolar pacemaker erosion or infection in all instances without further infection or complication.     

Subclavian cannulation. Valuable dialysis access alternative

The subclavian vein was used for temporary dialysis access in 67 patients. There were 733 dialysis treatments performed using a total of 87 catheters during the study period. The catheters were left in place for an average of 24.5 days per patient and 18.9 days per catheter. A mean of 10.9 dialysis treatments per patient, and 8.4 dialysis treatments per catheter were performed. Seven patients expired with their catheters indwelling. None of these deaths were related to the catheter. There were 21 associated catheter complications. Twelve of these catheter complications were corrected by changing the catheter over a guide wire. The technique for catheter insertion, proper catheter care including home care, and complications due to the catheters are discussed. Subclavian catheter dialysis access appears to be a valuable adjunct for dialysis and has replaced the use of Scribner shunts and repeated femoral catheterizations for temporary access in our institution.     

Treatment of severe pulmonary hemorrhage after cardiopulmonary bypass by selective, temporary balloon occlusion

Severe pulmonary bleeding causes frequent mortality, particularly if this event occurs during separation from extracorporeal circulation during cardiac surgery. We present a new approach to treat this life-threatening complication: temporary balloon occlusion of the pulmonary artery feeding the involved lobe. On attempting to wean a 71-yr-old female patient from cardiopulmonary bypass after aortic valve replacement, she lost more than 2 L of blood through her trachea over approximately 15 min and severe gas embolism into the left atrium was visualized on transesophageal echocardiography. As the bleeding was too vigorous to be localized by fiberoptic bronchoscopy, an interventional cardiologist was consulted. After localizing the affected lobe using fluoroscopy, he inflated a balloon dilating catheter in the lower lobe artery. This effectively stopped the bleeding. Separation from extracorporeal circulation was uneventful using one-lung ventilation to prevent further gas embolism. Sixteen hours after the end of surgery the catheter could be deflated and removed without any further intervention. The patient made an excellent recovery.     

Elevation of plasma D-dimer is closely associated with venous thrombosis produced by double-lumen catheter in pre-dialysis patients.

BACKGROUND: A double-lumen catheter (DLC) is used as a temporary blood access in emergency haemodialysis and continuous haemodialysis. There are various reports concerning thrombosis related to use of DLC and other catheters. The objective of this study is to assess the incidence of venous thrombosis when using DLC in patients undergoing blood purification. Method. Forty-eight Japanese patients, hospitalized in the Saitama Medical University hospital from December 2004 to April 2005, who had DLC insertion as a temporary blood access for blood purification. The existence of a thrombus was determined using ultrasonography, before catheter insertion, and every 2 days after insertion up to 3 weeks. At the time of DLC insertion, general blood tests including plasma D-dimer, and serum C-reactive protein (CRP) were performed. When DLC was removed, plasma D-dimer and serum CRP were measured. RESULTS: In 30 of 48 (62.5%) patients with DLC insertion as a temporary blood access for haemodialysis, venous thrombi with diameters>1.1 mm were detected by venous ultrasonography. No predictive factors were recognized except an increase in plasma D-dimer that was significantly higher in the patients with venous thrombus. The changes in plasma D-dimer were 3.54 (SE 0.8) microg/dl in patient with thrombus, and 0.29 (0.30) microg/dl in patient without thrombus (P=0.004). CONCLUSIONS: The study suggests that changes in plasma D-dimer after the insertion of the catheter may be used to predict thrombus formation and is more accurate than baseline measurements, and easier than other new markers.     

Outcome after treatment of detrusor-sphincter dyssynergia by temporary stent

OBJECTIVES: To evaluate follow-up treatments used after treatment of detrusor-sphincter dyssynergia (DSD) by a temporary urethral sphincter stent. MATERIALS AND METHODS: Between February 1994 and June 2003, 147 men with a mean age of 41.3+/-14.4 years were treated by temporary urethral stent inserted across the external sphincter for DSD. The underlying neurologic disease was quadriplegia in 85 cases, multiple sclerosis in 24 cases and paraplegia in 21 cases. A Nissenkorn (Bard) stent was used in 130 cases and a Diabolo (Porgès) stent was used in 17 cases. All patients were either unable to or they refused to perform intermittent self-catheterization. DSD was demonstrated by urodynamic studies in every case. RESULTS: The mean duration of temporary stenting was 10.15+/-16.07 months. After temporary stenting, 92 patients were treated by permanent stent (Ultraflex, Boston Scientifics), 7 started intermittent self-catheterization, 12 had repeated changes of the temporary stent, 4 had an indwelling catheter, 3 underwent cystectomy with non-continent diversion, 2 were treated by endoscopic sphincterotomy, 1 was treated by bladder neck incision, 1 was treated by neuromodulation and 1 was treated by cystostomy. Fifteen patients were lost to follow-up. Two patients died during follow-up (not related to DSD). CONCLUSION: After treatment of DSD by a temporary urethral sphincter stent, 70.7% of patients subsequently require a permanent urethral sphincter stent. This period allows selection of patients unlikely to benefit from permanent urethral sphincter stent.     

Balloon catheter tamponade in cardiovascular wounds

From 1980 to 1990, operative balloon catheter tamponade was used in 12 patients with cardiac or vascular injuries from penetrating wounds. In nine patients, a balloon catheter was passed into a bleeding site through a bullet track or proximal artery and inflated with saline or radiologic dye. In two of these patients, the proximal balloon catheter was folded on itself, tied in that position, and left in the patient permanently. In the other seven patients in this group, the balloon catheter was attached to a three-way stopcock and left temporarily inflated postoperatively. These patients were then observed in the intensive care unit for 3 to 4 days, at which time the balloon was withdrawn. Eight of nine patients survived without recurrent hemorrhage after removal of the balloon catheter, while one patient with a Fogarty balloon placed in the carotid siphon died of a cerebral infarction. Balloon catheter tamponade was also used on a temporary basis in one patient with a posterior cardiac wound and in one patient with an anterior stab wound of the inferior vena cava at the renal veins, whereas in two patients with high cervical arteriovenous fistulas, one had permanent placement of the balloon catheter while the other had temporary placement. One of the latter patients also had acute hemorrhage. Although all four patients survived, one of the patients with a fistula developed a recurrence and another required two separate operative procedures for correct placement of the balloon to cure the fistula.     

Constant infusion of morphine for intractable cancer pain using an implanted pump

In the past, pain control for chronic pain syndromes using narcotic infusion has been carried out primarily via the intrathecal (subarachnoid) route. This report presents one of the first large series of terminally ill cancer patients with intractable pain treated with continuous epidural morphine infusions by means of implanted pumps and epidural spinal catheters. The purpose of the study was to demonstrate that the epidural route is effective with minimal complications, and that screening with temporary epidural catheter infusions results in a high rate of subsequent pain relief. A multidisciplinary team (neurosurgeon, anesthesiologists, psychiatrists, oncologists, and nurse clinicians) evaluated and treated all of the patients studied. Percutaneous placement of temporary epidural catheters for a trial assessment was performed by the anesthesiologists. Pain evaluations were conducted independently by psychiatrists using both verbal and visual analog scales. From 1982 to 1988, 41 (59.4%) of 69 patients evaluated for eligibility experienced good pain control during trial assessment and were subsequently implanted with Infusaid infusion pumps. Preinfusion pain analog values were 8.6 +/- 0.3 and postimplantation values at 1 month were 3.8 +/- 0.4 (p less than 0.001). Over this same 1-month period. requirements of systemic morphine equivalents decreased by 79.3% with epidural infusions as compared to preinfusion requirements (p less than 0.001). There were no instances of epidural scarring, respiratory depression, epidural infections, meningitis, or catheter blockage. One patient developed apparent drug tolerance and three patients required further catheter manipulations. This series strongly suggests that significant reductions in cancer pain can be obtained with few complications and a low morphine tolerance rate using chronic epidural morphine infusion. Anesthesiology and psychiatry input, along with temporary catheter infusion screening and quantitative pain evaluations using analog scales, are essential.     

脊髓损伤患者的反射性排尿与自主神经过反射

Ｔ６以上脊髓损伤所致的截瘫或四肢瘫患者在损伤平面以下受到强烈刺激后，可引起自主神经过反射。为了明确膀胱叩击与自主神经过反射的关系，对１０例颈髓损伤四肢瘫和１０例Ｔ６以下脊髓损伤截瘫患者，测量安静时及膀胱充盈后连续叩击膀胱时的血压和心率，将所测得参数行统计学处理和比较。结果表明：四肢瘫病人在膀胱充盈后连续叩击膀胱可以引起反射性排尿，但也引起明显的自主神经过反射。通过反复试验，发现在髂前上棘与耻骨结节连线中点偏下处连续叩击腹壁可引起反射性排尿，但并不诱发自主神经过反射。     

Continuous epidural perfusion of morphine and bupivacaine for post-thoracotomy analgesia. Comparison between thoracic and lumbar epidural analgesia]

Relief of postoperative pain and the incidence of side effects occurring after continuous epidural infusion of morphine and bupivacaine were evaluated in patients undergoing a thoracotomy. We also studied the relevance of a close proximity of the epidural catheter to the metameric segment were the pain originated. The study involves 17 patients divided into two groups. In one series (lumbar group) (LG) the catheter was located at the lumbar region and in the other series (thoracic group) (TG) the catheter was localized at the thoracic area. The study was carried out during the first 48 hours following surgery. Bupivacaine 2% and 0.2 mg/ml of morphine hydrochloride were administered at an initial rate of 1.5 ml/h. The total dose required for pain relief was greater in LG than in TG (p less than 0.05). There were no significant group differences in the hemodynamic and respiratory parameters measured in this study. Only respiratory rate was occasionally lower in LG. Three patients presented postoperative atelectasis (2 in TG and 1 in LG) and required bronchoscopy. One patient of LG complained pruritus and another one of the same group presented nausea and vomiting. The epidural perfusion was interrupted in only one patient of TG due to the presence of arterial hypotension. The association of narcotics and local anesthetics in continuous epidural perfusion was an excellent method for achieving pain relief with minimum side effects. We conclude that both thoracic and lumbar epidural routes are advisable for post-thoracotomy pain relief.     

Haemodialysis catheter-related right transverse cervical artery pseudoaneurysm and treatment by coil embolization

In patients with end-stage renal disease, temporary placement of venous catheters for haemodialysis (HD) is often necessary, and the right internal jugular (RIJ) vein is the usual preferred site of HD catheter placement. We report here a patient who experienced complications because of the development of a pseudoaneurysm of the transverse cervical artery following an apparently uneventful RIJ vein cannulation for temporary HD, using the blind landmark-guided technique. This is a rare complication of RIJ vein cannulation and HD catheter placement. The pseudoaneurysm presented 3 weeks after the procedure and was diagnosed by using colour-Doppler ultrasound, followed by an angiogram, and it was successfully occluded using endovascular coil embolization.     

A safe technique for the precise localization of carotid-cavernous fistula during balloon obliteration. Technical note

The authors report a technique to precisely localize a fistulous opening in the carotid artery. The patient is heparinized and a Prolo catheter is introduced into the internal carotid artery and inflated distal to the approximate site of the fistula. Heparinization allows the balloon to be inflated long enough to obtain and analyze high-quality angiography film without fear of thromboembolism generated by the temporary balloon occlusion. Contrast material injected through the Prolo catheter proximal to the balloon reveals a small segment of cavernous carotid artery between the inflated balloon distally and the fistula proximally. The venous structures are now only faintly opacified and cannot obscure the morbid anatomy of the exact fistulous tear in the carotid artery. If the balloon is placed exactly opposite to the site of the fistula, a standing, stagnant column of dye forms a cast of the cavernous, petrous, and cervical carotid artery. Once the fistula is localized with this method, it may be obliterated by any therapeutic means preferred. If the Prolo catheter is used for intraluminal occlusion, then a transfemoral contralateral carotid angiogram is done before the heparin is reversed to confirm that the balloon has not been placed proxial to the fistula.     

Difficult removal of a wire-reinforced epidural catheter

We report a case of epidural catheter shearing, an uncommon complication of removal of a wire-reinforced epidural catheter. The catheter was removed without incident, and with the tip intact, after we allowed the patient to relax for 3 hours, placing the patient in the lateral decubitus position, and placing continuous tension on the catheter itself so as to let it "work its way out".     

Successful management of bilateral carotid-cavernous fistulae with a trans-sphenoidal approach.

A patient with traumatic bilateral carotid-cavernous fistulae was successfully treated by an entirely extracranial approach. The larger fistula on the left was exposed via a transethmoidal, trans-sphenoidal route and was directly opened and packed while the cavernous carotid artery was stented open by an intraluminal balloon catheter. The balloon catheter provided temporary hemostasis and was removed after the fistula had been packed. The left carotid artery remained patent, and the smaller fistula on the right was subsequently obliterated by a balloon catheter. The fistulae have remained cured, and the left internal carotid artery supplies the cerebral circulation.     

Urethral stents in benign prostate hyperplasia

Management of lower urinary tract symptoms resulting from benign prostate hyperplasia in the high-risk surgical patient presents a unique challenge. Continuous urethral catheter drainage is associated with a significant decrease in the quality of life and a higher risk of urinary tract infections, bladder calculi, and hematuria. Urethral stents offer a theoretically attractive alternative to Foley catheter drainage. Newer designs allow selection of stent characteristics based on patient need. Urethral stents may be permanent or temporary. The history of urethral stent design and patient experience is reviewed in this article.     

Delayed vocal fold paralysis after continuous interscalene level brachial plexus block with catheter placement: a case report

We report an incident of delayed onset of true vocal fold paralysis with continuous interscalene brachial plexus block. A 51 year old woman underwent left shoulder manipulation and lysis of adhesions with fluoroscopy and general anesthesia. An interscalene brachial plexus block was performed and a catheter with a continuous infusion pump was placed for postoperative pain control. Following hospital discharge, approximately 8 hours after the initial catheter bolus the patient developed hoarseness, dysphagia, and dyspnea, secondary to left vocal fold palsy. The patient was admitted for observation and the catheter was discontinued with no intubation required. By the next morning, the patient’s dysphagia and dyspnea had resolved and her hoarseness improved.     

Long-term use of nerve block catheters in paediatric patients with cancer related pathologic fractures

We report three cases of children with osteosarcoma and pathologic fractures treated with long-term continuous nerve blocks for preoperative pain control. One patient with a left distal femoral diaphysis fracture had a femoral continuous nerve block catheter for 41 days without complications. Another with a fractured left proximal femoral shaft had three femoral continuous nerve block catheters for 33, 26 and 22 days respectively. The third patient, whose right proximal humerus was fractured, had a brachial plexus continuous nerve block catheter for 36 days without complication. In our experience, prolonged use of continuous nerve block is safe and effective in children with pathologic fractures for preoperative pain control.     

Die kontinuierliche Nervus-suprascapularis-Blockade zur Schmerztherapie der Schulter

This study assesses a modified approach for suprascapular nerve block in a single shot and continuous catheter technique for the treatment of chronic shoulder pain. After thorough anatomic examinations, a new technique was performed in 30 patients by inserting the catheter into the suprascapular fossa. Complications of the technique, time of onset, effect and patient satisfaction were evaluated. The results show that there were no complications due to the technique and only one patient had a minor VAS score during physiotherapeutic exercise. Local inflammation occurred in one patient and dislocation of the catheter in another patients. Patient satisfaction (97%) was very high. The modified technique of continuous suprascapular nerve block is a safe and easy-to-perform technique in the treatment of acute and chronic shoulder pain.