Entrapment of a Swan Ganz catheter in an IVC filter requiring caval exploration. A case report

The placement of Swan Ganz (SW) catheters and inferior vena cava (IVC) filters are common procedures performed in critically ill patients. Many reports describe the independent misplacement of SG catheters and IVC filters, and others have reported migration of IVC filters and entanglement of various intravascular devices in IVC filter. Our patient is a 70-year-old Caucasian woman who underwent an aortic valve replacement and coronary artery bypass grafting. The patient developed a deep venous thrombosis and an infrarenal IVC filter was placed without incident. A Swan Ganz catheter was placed later in the postoperative period and became entangled in the IVC filter. We advised operative removal after several unsuccessful percutaneous attempts to retrieve the catheter. IVC filters are indicated for prevention of fatal pulmonary emboli in patients with a contraindication to anticoagulants or with recurrent embolism despite adequate anticoagulant therapy. Complications of IVC filters include caval thrombosis, retroperitoneal hemorrhage and perforation of the IVC, hepatic veins, duodenum and aorta. We describe our evaluation and operative approach and make recommendations for prevention of entangling the SG into the IVC filter.     

The Impacts of Super Obesity Versus Morbid Obesity on Respiratory Mechanics and Simple Hemodynamic Parameters During Bariatric Surgery

Background

This study was designed to determine the impact of the degree of obesity on respiratory mechanics and simple hemodynamic parameters at laparoscopic bariatric surgery.

Methods

The patients were divided into two groups, each of which included 24 patients (a morbidly obese group and a super obese group) undergoing laparoscopic bariatric surgery. Dynamic respiratory compliance, respiratory resistance, and peak inspiratory pressures were measured at four time points: 10 min after anesthesia induction (T1: induction), 10 min after pneumoperitoneum (T2: pneumoperitoneum), 10 min after terminating pneumoperitoneum (T3: end-pneumoperitoneum), and before extubation (T4: extubation). The systolic, diastolic, and mean arterial pressures and the heart rate values were measured noninvasively in T0 (10 min before operation).

Results

Obesity was found to cause a statistically significant increase in respiratory resistance and a peak inspiratory pressure and a decrease in dynamic respiratory compliance. In the morbidly obese group, the lowest dynamic respiratory compliance was 37?±?12 mL/cm H₂O, but it was 33?±?13 mL/cm H₂O in the super obese group. The systolic pressure, diastolic pressure, and mean arterial pressure were found to decrease significantly in both groups.

Conclusions

Morbid obesity and super obesity have negative effects on hemodynamics and respiratory mechanics.     

Can the Stone Scoring Systems Be Used to Predict Infective Complications of Retrograde Intrarenal Surgery?

ObjectiveWe aimed to evaluate whether the retrograde intrarenal surgery (RIRS) scoring systems (Resorlu-Unsal Stone Score [RUSS], modified Seoul National University Renal Stone Complexity Score [modified S-ReCS], and R.I.R.S. score) can predict the infective complications after RIRS.Subject and MethodsA total of 581 patients who underwent RIRS for kidney stones were included in the study. All patients were evaluated for demographic data, medical history, radiological imaging methods before surgery, duration of surgery, and hospitalization time after surgery. Stone laterality, stone burden, stone size, stone density, the number of stones, stone localization, the presence of congenital kidney anomaly, and solitary kidney were evaluated preoperatively by computed tomography. The RUSS and modified S-ReCS and R.I.R.S. score of all patients were determined.ResultsInfective complications were detected in 47 (8.1%) patients who underwent RIRS. Fever developed in 27 subjects (4.6%), urinary infection in 15 (2.5%), sepsis in 2 (0.3%), and septic shock in 3 (0.5%) patients. In multivariate logistic regression analysis, age (OR = 1.8; 95% CI = 1–3.4; p = 0.049), surgical duration of >60 min (OR = 1.9; 95% CI = 1.1–3.5; p = 0.027), and high R.I.R.S score (OR = 8.9; 95% CI = 1.9–42.4; p = 0.006) were shown to be independent risk factors for the infective complications after RIRS. A receiver operating characteristic curve analysis showed that the R.I.R.S. score can be used as a marker to predict infective complications (AUC = 0.619, CI = 0.55–0.69; p = 0.007).ConclusionWe suggest that the R.I.R.S. score can be used to predict infective complications in RIRS.     

Proposed method to study the factors affecting local control with combined external beam and interstitial implantation of mobile tongue and floor of mouth

Twenty-seven patients with squamous cell carcinoma of the mobile tongue and floor of the mouth were treated with external beam and interstitial radiation. Good prognostic factors were T1N0, T2N0, superficial tumors, tumor shrinkage by 75% with external beam, and no apparent tumor clinically 2 months after treatment. On the other hand, T3N0, T1-3N1, and deeply necrotic tumors had a poor prognosis. We recommend using a flexible afterloading system to implant the initial local tumor volume (not just the residual nidus) that does not exceed 45 cm3. The minimum (reference) dose was prescribed to a surface 1/2 cm beyond the most peripheral rim of radioactive sources. For acceptable local control and complication rates, our suggested minimum (reference) doses are less than or equal to 7,500 rads for T1 (or a time-dose-fractionation [TDF] of 131-140), less than or equal to 8,000 rads for T2 (TDF of 131-140), and probably less than 8,500 rads for T3 (TDF of less than or equal to 150). These guidelines should be considered preliminary.     

Can scare tactics and fear-based messages help deter substance misuse: a systematic review of recent (2005–2017) research

Introduction: Historically, substance use prevention relied heavily on scare tactics and fear-based messages. However, these messages were discouraged from use due to research finding them ineffective or harmful. This review sought to determine if recent research continues to support this finding.

Methods: We conducted a literature review of relevant peer-reviewed studies from 2005 to 2017, categorising results as showing clear evidence of effectiveness, mixed evidence of effectiveness or no evidence of effectiveness. Research on historical scare tactics and fear-based messages was reviewed as a baseline and research on related theoretical models was reviewed for context.

Results: We identified 17 studies that met our inclusion criteria: 10 targeting tobacco use, five targeting alcohol use, one targeting marijuana use and one targeting methamphetamine use. Eight (8) studies found that these messages were more effective at influencing substance use-related measures than positive emotion prevention messages or control messages. Five (5) studies found mixed evidence, and four (4) studies found no evidence of effectiveness.

Discussion: Though not conclusive, our results suggest that these messages may be more effective than previously shown. However, many of the studied messages differed in tone and content from similar, historical messages. Organizations interested in implementing these messages should note these differences.     

Anticoagulant activity of enoxaparin and unfractionated heparin for venous thromboembolism prophylaxis in obese patients undergoing sleeve gastrectomy

BackgroundOne risk of bariatric surgery is venous thromboembolism and the optimal strategy to reduce risk requires further clarification.ObjectivesThe objectives of this study were to identify antiXa goal attainment with the institutional standard chemoprophylaxis, analyze discordance between antiXa and thrombin generation assay (TGA) in terms of adequacy of anticoagulation, and to identify correlations between patient characteristics or covariates and markers of coagulation status.SettingLarge academic medical center in Northeastern United States.MethodsA total of 60 sleeve gastrectomy patients were enrolled in this institutional review board–approved, prospective cohort study. Patients received the institutional standard prophylactic therapy (subcutaneous enoxaparin 40 mg twice daily or unfractionated heparin [UFH]). The UFH dose was weight based, 5000 units (<120 kg) or 7500 units (≥120 kg) every 8 hours. Various measures of coagulation status were measured at or near steady state.ResultsPatients receiving enoxaparin achieved goal antiXa more frequently compared with the UFH group, and statistical significance was demonstrated (93.8 % versus 4.5%, respectively; P < .0001). Target endogenous thrombin potential reduction from baseline was more frequently obtained in the enoxaparin group versus UFH (50% versus 27.7%, respectively; P = .12). AntiXa was below the limit of detection for the majority of UFH patients; while TGA suggested patients did experience anticoagulation at some level of effectiveness. Endogenous thrombin potential change in the enoxaparin group was correlated to several measures of body composition.ConclusionsPatients receiving enoxaparin achieved goal antiXa more often versus UFH. There was discordance between antiXa and TGA-based assessment of coagulation status. TGA may provide a more robust assessment of the adequacy of chemoprophylaxis.