Extended subcutaneous tunnelling technique for external ventricular drainage

Infection is a serious complication of external ventricular drain (EVD) and various strategies have been adopted to minimize its occurrence. The use of an extended subcutaneous tunnel (50-60 cm) was previously described, but has since received little attention in the literature. The authors reviewed their experience with this technique, with emphasis on the rate of infection and predisposing risk factors. This is a retrospective review of 114 patients who received EVD with extended subcutaneous tunnel ('long EVD'). Fourteen of the 114 patients underwent more than one insertion, and a total of 133 cases of 'long EVD' were included. The mean duration of drainage was 20 days. One-hundred-and-three cases started without pre-existent infection and seven became infected, yielding an overall infection rate of 6.8%. The majority of infections were found within the first 5 days and in the third week of drainage. There was, however, no statistically significant difference in daily infection risks between the first, second and third weeks. Only intraventricular instillation of urokinase was identified as a statistically significant risk factor. Non-infective complications occurred in 17 cases (12.8%). In the present study, the overall infection rate of the 'long EVD' was comparable with that of conventional EVD, as reported by other authorities in the literature. The extended subcutaneous tunnel technique did not affect the daily infection risk on a week-to-week basis. The 'long EVD' does not appear to offer any distinct advantage over the standard tunnelling technique in our unit. However, this is essentially an audit within a single centre, and the findings should be interpreted with caution and with the understanding that individual institutions may have their unique patterns and risks of EVD infection.     

Roman medical instruments from Lower Moesia

To elucidate the evolution of society over time, ancient medicine is a very interesting and important researching field. Archaeological discoveries, such as the objects described by this article, but other ancient sources, also, are able to provide a complex framework of medical practice in Roman times. The geographic area that we have like target in this material is the province of Lower Moesia, which includes the territory between Danube and Black Sea (Romanian Dobrodja) and northern Bulgaria. In the present study we present nine ancient medical instruments, from a private collection: two tweezers, two ear probes, a probe-spatula, a probe-spoon, a spoon for pharmacy and two fragments of some kind of hooks used in surgical operations. Most likely, we have a mixed medical kit with tools used in general medicine, surgery, in preparation of the pharmaceutical treatments, but very possible, also, in cosmetic practices. Publication of these archaeological materials is, in addition to an extra page in the history of ancient medicine, a pretext for stepping up in a research field that, in other regions of the former Roman Empire, it is a great interest for researchers.     

Epidural catheter fixation: subcutaneous tunnelling with a loop to prevent displacement

A method of fixing the epidural catheter by subcutaneous tunnelling and looping was devised. A prospective, randomised, double-blind, clinical trial was conducted in 68 adult patients, where postoperative pain relief was planned by thoracic epidural analgesia. In the tunnelled group (n = 34), the epidural catheter was fixed with a subcutaneous tunnel and loop, whereas in controls (n = 34), a simple loop of epidural catheter was left over the skin without tunnelling. An adhesive dressing was used to secure the epidural catheter. We observed that catheter dislodgement occurred in only one patient in the tunnelled group compared to seven control patients (21%). Despite local inflammation of the skin around the tunnel in nine patients (27%), no catheter infection (positive culture tip) was found in patients with subcutaneous tunnelling for the extended period of 4-5 days. The method described allows the catheter to lie flat on the skin and outward traction of the catheter during movement of patients is dampened by the interposed loop which protects it against dislodgement. At the time of removal, both ends of the catheter can be removed under direct vision. In conclusion, we recommend this fixation method in cases where epidural analgesia is to be used for postoperative pain relief.