Partial anomalous pulmonary vein drainage of the left lower lobe: incidental diagnostic after central venous cannulation

OBJECTIVE: To report a case of partial anomalous pulmonary vein drainage of the left lower lobe diagnosed after central venous cannulation. DESIGN: Retrospective case review. SETTING: Intensive care unit. PATIENT: A 76-yr-old woman with obstructive acute renal failure requiring hemodialysis. INTERVENTIONS: Central venous cannulation and hemodialysis. MEASUREMENTS AND MAIN RESULTS: The diagnosis was suggested by chest radiography after placement of a central venous catheter through the left internal jugular vein. Pressure measurements at the tip of the catheter showed a venous waveform. Oxygen blood content on samples of blood was higher than on peripheral arterial blood. Computed tomography with intravenous contrast was not conclusive. Diagnosis was confirmed with transcatheter phlebography. CONCLUSIONS: It is important for the intensivist to be aware of this infrequent variant when a central venous catheter takes an abnormal route and drains low-pressure, arterialized blood.     

Retrieval of fractured dialysis catheter through phlebotomy of internal jugular vein: a case report

A central venous catheter is the most common access for initiating hemodialysis. Prolonged access through a central venous catheter increases the risk of infection and dysfunction of the catheter with potential development of catheter-induced thrombosis and embolism. However, fracture and dislodgement of the catheter with subsequent embolization is an unexpected complication. Endovascular treatment is a promising method to remove intravascular foreign bodies. We herein report a case of a 58-year-old woman undergoing prolonged hemodialysis who required central venous catheter removal because of mechanical fracture of the tunneled cuffed catheter and its migration in the internal jugular vein. An urgent chest X-ray showed that the two free ends of the fractured tunneled cuffed catheter were located in the right atrium and right internal jugular vein. Phlebotomy of the internal jugular vein was successfully performed to retrieve the fractured tunneled cuffed catheter and the associated thrombi. In this case, phlebotomy for retrieval of the embolized catheter fragment extending into the right atrium was a safe alternative to an endovascular technique of catheter fragment retrieval. Phlebotomy preserved the integrity of the catheter fragment and its associated thrombus and was both cost-effective and safe.     

Percutaneous Central Venous Access for Resuscitation in Trauma

Objective: To determine the safety of percutaneous central venous access when used for trauma resuscitation and whether the initial hemodynamic status of the patient or the site of placement affects the ease or success of line placement. Methods: Consecutive major-trauma patients were managed using a resuscitation protocol guiding intravenous line use. Percutaneous peripheral venous access was initially attempted in all patients. If this approach was unsuccessful or proved to be inadequate for volume resuscitation, venous access was attempted using central venous catheter-introducer sets. The site of the central venous access was determined by protocol. For thoracic injury, access was via the ipsilateral subclavian vein (SCV), the ipsilateral internal jugular vein (IJV), or the femoral vein. For suspected mediastinal injury, access was via the contralateral SCV or IJV, or the femoral vein. For abdominal or flank injury, access was via the SCV or IJV only. Multiple central venous access sites were used at the discretion of the trauma team. Results: Central venous access was successful at 144 of 147 sites (99%) used in 122 patients during the study period. There was only one major complication (rate = 0.7%; 95% CI 0.0–3.8%). Mean catheter placement time was 1.9 minutes, and cannulation occurred with a mean of 1.8 needle passes. Most patients (81/122) were hypotensive (blood pressure ≤90 torr) at the time of line placement, including 44 who were in cardiac arrest and four awake patients who had no obtainable blood pressure. Neither the access site nor the presence of hypotension was associated with the mean time to obtain central venous access, the mean number of attempts, or the complication rate. Conclusion: Percutaneous central venous access is relatively safe and reliable for gaining intravenous access when resuscitating trauma patients, when used in a center where physicians are experienced in the technique. Consideration should be given to expanding the use of central venous access in trauma resuscitation.     

采用不同血管通路采集自体外周血造血干细胞的安全性及有效性评估

目的 探讨采用不同血管通路采集自体外周血造血干细胞的安全性及有效性。方法 2012年1月～2014年11月期间行自体外周血造血干细胞采集的87例患者分为两组:外周静脉采集组43例,均采用16G一次性内瘘针进行穿刺,进血管路选用肘部静脉,返血管路选用大隐静脉。中心静脉采集组44例,均采用双腔股静脉置管建立静脉通路。自体外周血造血的采集均选用Cobe Spectra血细胞分离机的Spectra Auto PBSC操作程序进行。观察两组患者在穿刺成功率、采集顺利程度、患者术中耐受度、采集过程中的不良反应以及最终采集物中单个核细胞数和CD34⁺细胞计数的差异。结果 两组患者采集的自体外周血单个核细胞数及CD34⁺细胞计数间差异无统计学显著性意义(t=4.159,3.147,P＞0.05),且均采集达标; 采集过程中不良反应在两组患者中差异无统计学显著性意义(χ²=0.000 9,P＞0.05); 但采用中心静脉组患者穿刺成功率高、采集顺利、患者术中耐受性均高于采用外周静脉通路的患者,差异有统计学意义(χ²=7.944,13.772 9,20.509 4,P＜0.05)。结论 采用双腔股静脉置管建立中心静脉通路在自体外周血干细胞采集中具有穿刺成功率高,采集顺利,最大程度减轻了患者的痛苦,且不影响采集效率和效果的优势。     

Vascular access in neonates and infants--indications, routes, techniques and devices, complications

Venous cannulation has been in regular use in neonates since the 1940s. This was at first through the umbilical vein, but the frequency of complications lead to other central and peripheral routes being used for infusion of fluid, nutrients and drugs. Today, peripheral venous access is preferred except for high volume fluid resuscitation, reliable infusion of irritant drugs and long-term parenteral nutrition. Intraosseous infusion provides a reliable alternative to peripheral veins for rapid infusion of fluid. Long, thin silastic catheters can be inserted through a peripheral venous cannulae for parenteral nutrition or other central venous infusions as an alternative to direct central venous cannulation using the Seldinger or other techniques. Broviac or Hickman catheters, inserted through a subcutaneous tunnel are only considered when central venous cannulation is likely to be needed for more than six weeks. The most common serious complication of vascular access is infection. Infection associated with central venous catheters is reduced by prophylactic vancomycin or teicoplanin. Other complications of central venous infusion are associated with cannulae malpositioning, bleeding and thrombosis. Distal hypoperfusion may follow arterial cannulation. Modern emergency and intensive care paediatrics is impossible without adequate venous and arterial vascular access. However no other skill for neonatal intensive care causes more anxiety in primary care providers or is more difficult to teach.     

Peripherally inserted central catheters--use in home care

Reliable vascular access is essential for any type of intravenous therapy. The movement of many intravenous therapies to the home setting has placed a greater burden on home care nurses to maintain reliable vascular access. In the past, when peripheral venous access became unmanageable, a central venous device such as a tunneled silastic catheter or a polyurethane subclavian line was placed. Peripherally inserted central venous catheters now offer an alternative to this type of device. These devices, nicknamed long-arm or long-line catheters, are providing reliable vascular access for many therapies. They are inserted by specially trained nurses in the home. They offer fewer complications, decreased cost and improved patient comfort. The phlebitis rate and other catheter-related complications are examined. Nurse training and insertion procedures are explored in this small pilot study.     

经狭窄或闭塞的中心静脉置入长期透析导管的临床研究

目的探讨血管资源已耗竭的血液透析患者永久性血管通路的建立方法。方法 6例无法建立动静脉内瘘并有多次多部位中心静脉导管留置史的维持性血液透析患者,经血管彩超及CT血管造影(CT angiography,CTA)证实存在多处中心静脉狭窄或闭塞,对其狭窄或闭塞的头臂静脉行经皮腔内球囊扩张血管成形术(percutaneous transluminal angioplasty,PTA),然后经颈内静脉途径置入长期中心静脉导管。结果术后应用导管透析,1例患者第2次透析时血流量仅达180ml/min,调整导管位置后血流量达到250ml/min以上,其余患者血流量均在250ml/min以上,随访2～6个月,所有患者均未出现导管功能不良及感染。结论对于血管资源耗竭的患者,通过介入治疗开通狭窄或闭塞的中心静脉留置长期透析导管,是一个安全有效的建立永久性血管通路的方法。     

Doppler sonographic findings in children with idiopathic portal vein cavernous deformity and variceal hemorrhage.

OBJECTIVE: To describe the flow patterns in the portal vascular territory in children with portal vein cavernous deformity. METHODS: The study included 12 children (age 4-10 years) with hematemesis, melena, or both in whom B-mode gray scale sonography revealed small anechoic spaces replacing the site of the portal vein. The portal vein cavernous deformity was present either alone (in 8 patients) or with congenital hepatic fibrosis (in 4). Doppler sonography (color and spectral) was performed to assess the flow in the portal vascular territory, splenic vein, intrasplenic veins, and abdominal collaterals. RESULTS: Doppler sonography confirmed the venous flow waveform in the cavernous portal vein in all children with normal flow direction in the few intrahepatic portal vein branches and also in the intrahepatic veins. Splenomegaly was present in all. The intrasplenic veins were dilated in all but had normal flow direction except in 2 with spontaneous trans-splenic shunts. Gallbladder varices were shown in 4 patients, and perisplenic collaterals were shown in 3. CONCLUSIONS: Doppler sonography is a valuable noninvasive imaging technique for assessment of the portal hemodynamic profile in patients with portal vein cavernous deformity, which can affect subsequent treatment decision making. Trans-splenic shunts are uncommon, but this Doppler sonographic report documents such shunts in children with portal hypertension.     

Peripherally inserted central catheters (PICCs): do they have a role in the care of the critically ill patient?

Over an eight-month period, 177 patients were admitted to a study to determine whether there was any significant difference between the peripherally inserted central catheter (PICC) in relation to the central venous catheter (CVC) and the peripheral venous access device in respect of the length of stay, incidence of phlebitis and the need for removal for suspected sepsis and infection. The results demonstrated no significant difference in terms of gender, age, or severity of illness. The PICC line had a significally higher length of stay and less incidence of phlebitis. In conclusion, PICC placement does have a place in the critical care setting. It should not be expected to replace existing methods of vascular access but used to provide a safe and effective alternative.     

A huge intrahepatic portal vein aneurysm

Portal vein aneurysm is an unusual vascular abnormality. We report a rare case of a huge intrahepatic portal vein aneurysm at the umbilical portion with hepatic encephalopathy. Abdominal contrast-enhanced dynamic computed tomography and angiography clearly showed a well-circumscribed, 50 x 40-mm portal vein aneurysm at the umbilical portion with portohepatic venous shunt. To our knowledge, this is the largest intrahepatic portal vein aneurysm ever reported.     

特重度烧伤瘢痕患者应用经外周静脉穿刺置入中心静脉导管置管一例的护理体会

目的了解经外周静脉穿刺置入中心静脉导管(peripherally inserted central venous catheters,PICC)在大面积疑难烧伤病例中的作用及其使用情况。方法分析2016年7月上海市某三级甲等综合性医院烧伤科收治1例大面积深度烧伤后瘢痕增生患者,施行PICC置管的过程。结果由于该患者全身大面积瘢痕增生及手术部位限制无法建立外周静脉通道或中心静脉通道(central venous catheters,CVC),遂在超声引导赛丁格穿刺下成功置入PICC导管,留置52d,并顺利完成了相关治疗后拔管。结论该案例PICC的成功实施,拓宽了其在烧伤及疑难置管病例中的使用范围。     

血液透析患者血管通路选择和使用情况调查

目的回顾性分析血液透析患者血管通路的使用情况。方法记录自2012年1月1日至2012月12月31日全年新入血液透析患者及维持性血液透析患者的基本资料、原发病、血管通路的选择、变更次数、血管通路并发症的发生情况。结果全年血液透析患者157例。新入患者36例,新入患者开始透析时血管通路分别为:临时导管26例(72.2%),长期管2例(5.6%),自体动静脉内瘘6例(16.7%);维持性血液透析患者121例,其中应用自体动静脉内瘘109例(90.08%),长期管9例(7.4%),临时导管2例(1.65%),人造血管内瘘1例(0.83%)。自体动静脉内瘘并发症主要是血栓形成,肿胀手、肢体缺血,感染,并发症发生率为29.7%。中心静脉导管并发症主要为血流不足,深静脉血栓,感染;只有3例未出现并发症,并发症发生率为72.7%。本组患者原发病前三位依次为慢性肾炎(32.48%)、糖尿病肾病(28.66%)、慢性间质性肾炎(16.56%)。死亡前两位原因心血管疾病和脑出血,共占71.4%。结论研究资料中维持性血液透析患者的血管通路以自体动静脉内瘘为主,新入患者动静脉内瘘使用率低,中心静脉导管并发症明显高于内瘘,影响血管通路选择主要原因为糖尿病、高龄和透析时机过晚。     

Analysis of venous access for therapeutic plasma exchange in patients with neurological disease

We retrospectively analyzed our 2-year experience with venous access for 363 therapeutic plasma exchanges in 46 patients with neurological disease, including acute Guillain-Barré syndrome (N = 20), myasthenia gravis (N = 17), and chronic inflammatory demyelinating polyneuropathy (N = 9). Twenty-three patients (50%) completed the planned course of therapy using only peripheral venous access, and 28 central venous catheters were placed in the remaining 23 patients. Patients utilizing central venous access did not undergo a greater number of procedures, but they were more likely to have acute Guillain-Barré syndrome (P < 0.02) or to be hospitalized in a medical intensive care unit (P < 0.01). Three types of central catheters were used, and although our experience was predominantly with 1 type, differences were noted. Only 3% of procedures (3 of 96) done with a Quinton-Mahurkar catheter were associated with a catheter failure, compared to 27% (4 of 15, P < 0.01) with a Hickman catheter and 67% (2 of 3) with a triple-lumen catheter. Life-threatening complications occurred with 3 of 28 (11%) central catheters. To optimize the success of therapeutic plasma exchange using central access, it is critical that hemapheresis personnel advise each patient's primary physician regarding the type of central venous catheter required. Currently, we recommend use of a Quinton-Mahurkar or other dual-lumen hemodialysis catheter. © 1992 Wiley-Liss, Inc.     

Phlegmasia cerulea dolens with compartment syndrome: a complication of femoral vein catheterization

OBJECTIVE: Central venous catheterization is commonly performed in the critically ill. The femoral vein is widely accepted as an insertion site with complications thought to be comparable to other central access sites. We used serial ultrasound examinations with Doppler to examine the evolution of a heretofore undescribed complication of femoral vein catheterization, phlegmasia cerulea dolens with compartment syndrome. DESIGN: Serial ultrasounds were performed in patients before the insertion of femoral venous catheters and sequentially every 48 hrs while the catheters were in place. The noncatheterized leg served as a control. SETTING: A trauma and life support center of a tertiary multidisciplinary critical care unit. PATIENT: A 32-yr-old man with respiratory failure as a consequence of a severe community-acquired pneumonia that required central venous access for antibiotics because no peripheral sites could be obtained. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The initial ultrasound examination of both legs before femoral catheter insertion revealed no sign of venous thrombosis. Ultrasound of the catheterized leg at 48 hrs revealed a small nonocclusive thrombosis, whereas the opposite leg remained normal. At 72 hrs, the catheterized leg had clinical and ultrasonographic evidence of a massive thrombosis. A compartment syndrome defined by pressure measurements soon ensued and required emergent surgical release. CONCLUSIONS: This case report and a review of the available literature suggest that thrombosis associated with femoral vein catheterization should be considered when clinicians decide where to obtain central venous access when multiple sites are available. This report also suggests the utility of serial ultrasound examinations to define clinically nonapparent thrombosis as an early indicator of a potentially catastrophic complication.     

Clinical review: Alternative vascular access techniques for continuous hemofiltration

Obtaining or maintaining vascular access for continuous hemofiltration can sometimes be problematic, especially in the child or adult in multiple organ failure with edema and/or coagulopathy. Problems commonly encountered include obstruction of the femoral vein by the catheter, insertion difficulties, safety concerns when cannulating the subclavian vein in coagulopathy, and catheter and circuit occlusion due to disseminated intravascular coagulation. For access in infants we describe a technique utilizing two single-lumen thin-walled vascular sheaths. For infants and small children initial access to the vein may be difficult due to edema or poor perfusion. For this situation we describe the 'mini-introducer' technique of securing the vein and facilitating subsequent insertion of a relatively large guide wire. At any age an alternative route to the subclavian vein, from above the clavicle, is potentially 'compressible' in the event of hemorrhage during the procedure. We remind the reader of the utility of ultrasound guidance for cannulation of the internal jugular and subclavian veins. And lastly we review the options for venous return via the umbilical vein in infants, and via the antecubital vein in larger children and adults.     

Transhepatic venous approach to permanent pacemaker placement in a patient with limited central venous access

The end-stage renal disease population poses a challenge for obtaining venous access required for life-saving invasive cardiac procedures. In this case report, we describe an adult patient with end-stage renal disease in whom the hepatic vein was the only available access to implant a single-lead permanent cardiac pacemaker. A 63-year-old male with endstage renal disease on maintenance hemodialysis and permanent atrial fibrillation/atrial flutter presented with symptomatic bradycardia. Imaging studies revealed all traditional central venous access sites to be occluded/non-accessible. With the assistance of vascular interventional radiology, a trans-hepatic venous catheter was placed. This was then used to place a right ventricular pacing lead with close attention to numerous technical aspects. The procedure was completed successfully with placement of a single-lead permanent cardiac pacemaker.     

肾病综合征合并门静脉血栓形成(附1例病例报告)

目的提高对肾病综合征合并门静脉血栓形成的认识,探讨相关治疗心得。方法报告1例以门静脉血栓形成为首发表现的肾病综合征病例,并复习相关文献。结果男性,52岁,因“腹痛、腹胀伴蛋白尿1周”入院。当地以“急腹症”收住入院,予以相应抗炎、解痉、制酸等处理无好转,彩超提示“门静脉栓塞”,并行DSA检查确诊,同时发现大量蛋白尿、低蛋白血症,考虑肾病综合征合并门静脉血栓,用尿激酶等治疗无好转而转来本院。入院后给予以肝素、东菱克栓酶以及糖皮质激素等联合治疗。腹痛、腹胀等症状明显好转,复查尿蛋白转阴,多次复查彩超提示门静脉血栓进行性缩小,门静脉高压表现好转。出院随访至今病情稳定。结论深静脉血栓形成为肾病综合征严重并发症,以门静脉血栓形成且为首发症状较罕见,且病情较重。早期（6h内）尿激酶溶栓效果最佳,后期可以东菱克栓酶（DF-521）、肝素等为主要治疗手段;在治疗血栓时应同时治疗原发疾病-肾病综合征。     

Value of carbon dioxide wedged venography and transvenous liver biopsy in the definitive diagnosis of Abernethy malformation

We report a 25-year-old man who presented with congenital absence of the portal vein, or Abernethy malformation, a rare congenital disorder in which the mesenteric and splenic venous drainages bypass the liver and directly drain into the inferior vena cava through an extrahepatic portosystemic shunt. Magnetic resonance imaging, which showed multiple nodular lesions in both liver lobes that were associated with an absence of intrahepatic portal venous branches, strongly suggested the diagnosis of the Abernethy malformation. Carbon dioxide wedged venography and transvenous liver biopsy, which were performed in the same session by a right jugular approach, confirmed these findings. This technique can be considered a valuable alternative diagnostic tool to catheter arteriography and percutaneous transhepatic liver biopsy.     

Peripherally inserted central venous catheters for autologous blood progenitor cell transplantation in patients with haematological malignancies

Background In contrast to the high risk of haemorrhage associated with the implantation of a central venous catheter (CVC) via the internal jugular or subclavian access, the use of a peripherally inserted catheter (PICC) offers the advantage of a lower risk of bleeding complications. However, the rate of phlebitis is higher with the PICC and its use has been declining. We have studied the benefits and adverse events of a new type of PICC and a common type.Methods From October 1999 to October 2001, 70 PICCs (Olimpicc, Vygon, Germany, n=40; and LIFECATH-PICC(PUR)5FR Vygon, Germany, n=30) were inserted into 66 patients with haematological malignancies and used for high-dose chemotherapy, total parenteral nutrition and autologous blood stem cell transplantation. While removing the catheter, central and peripheral blood cultures were taken. The catheter tip was investigated by the semi-quantitative roll-out method of Maki.Results Sixty-five PICCs were removed after a median of 8.9 days. In five cases a catheter-associated significant colonisation with coagulase-negative staphylococci occurred. In two instances catheter-related bacteraemia was found.Conclusion In our study this catheter system was inserted in 94% of patients without problems and showed a low incidence of phlebitis (5/65). Because of the high rate of catheter malfunction reported during and after our study, the Olimpicc catheter is no longer available. The PICC system, and the LIFECATH-PICC(PUR)5FR in particular, offers a safe and effective alternative for central venous access to the internal jugular vein.     

腹壁浅静脉留置针穿刺在门静脉高压症中的可行性评价

目的 对40例门静脉高压患者行腹壁残静脉留置针穿刺从不同侧面评价留置效果。方法 以第四代“Y”型留置套管针,根据被选静脉血流方向,依靠左食、拇指的辅助作用,以10°～15°进针见血后妥然固定。结果观察组的腹壁浅静脉充盈度、可穿刺静脉数目非常明显优于对照组(P<0.01);其自然回血率、再次置管率明显高于对照组(P<0.05);以生理盐水对封管结果无明显影响(P>0.05)。结论 门静脉高压有广泛腹壁浅静脉侧支循环的建立与开放的病理基础,为浅静脉留置针穿刺提供了穿刺途径。