Ultrasound guidance for internal jugular vein cannulation: Continuing Professional Development

Purpose

The objective of this continuing professional development module is to describe the role of ultrasound for central venous catheterization and to specify its benefits and limitations. Although ultrasound techniques are useful for all central venous access sites, the focus of this module is on the internal jugular vein approach.

Principal findings

In recent years, several studies were published on the benefits of ultrasound use for central venous catheterization. This technique has evolved rapidly due to improvements in the equipment and technology available. Ultrasound helps to detect the anatomical variants of the internal jugular vein. The typical anterolateral position of the internal jugular vein with respect to the carotid is found in only 9-92% of cases. Ultrasound guidance reduces the rate of mechanical, infectious, and thrombotic complications by 57%, and it also reduces the failure rate by 86%. Cost-benefit analyses show that the cost of ultrasound equipment is compensated by the decrease in the expenses associated with the treatment of complications. In this article, we will review the history of ultrasound guidance as well as the reasons that account for its superiority over the classical anatomical landmark technique. We will describe the equipment needed for central venous catheterization as well as the various methods to visualize with ultrasound.

Conclusion

To improve patient safety, we recommend the use of ultrasound for central venous catheterization using the internal jugular approach.     

Homocysteine and markers of inflammation in acute coronary syndrome

BACKGROUND:

An elevated level of homocysteine (Hcy) has been shown to be a cardiovascular risk factor in the majority of research studies. Recently, it was found to be associated with new risk factors such as inflammatory markers.

OBJECTIVES:

To investigate the distribution of plasma total Hcy (tHcy) and the levels of inflammatory markers in patients with acute coronary syndrome (ACS), and to evaluate the association between these parameters and the severity of the disease.

METHODS:

A total of 122 patients with ACS and 80 control subjects were recruited from the cardiac intensive care unit of the Military Hospital of Tunis, Tunisia. Lipid profile and the levels of tHcy, high-sensitivity C-reactive protein (HsCRP), interleukin (IL)-6, IL-8, IL-1β and tumour necrosis factor-alpha (TNFα) were determined for all participants. The distribution of these parameters were compared between groups and according to the number of diseased vessels in patients with ACS.

RESULTS:

ACS patients had significantly elevated levels of tHcy (P<0.01), HsCRP (P<0.001), IL-6 (P<0.001), TNFα (P<0.001), folates (P<0.05) and vitamin B₁₂ (P<0.001), but lower high-density lipoprotein cholesterol (P<0.05) levels. The analysis of the association between these parameters and the number of diseased vessels showed significant differences in tHcy, HsCRP, IL-6 and TNFα, with positive correlations. Significantly negative correlations were found between the number of diseased vessels and folate (r=−0.34; P<0.01), and vitamin B₁₂ (r=−0.22; P<0.01).

CONCLUSION:

Elevated levels of tHcy, IL-6, TNFα and HsCRP appear to be associated with a greater number of diseased arteries and, consequently, the severity of coronary artery disease.     

“Rex Shunt” for the Treatment of Portal Vein Thrombosis After Pediatric Liver Transplantation: A Case Report

Background and Purpose

Late portal vein thrombosis (PVT) can be extremely well tolerated, although portal hypertension and other consequences of the long-term deprivation of portal inflow to the graft may be hazardous, especially in young children. Recently, the “Rex shunt” has been used successfully to treat these patients. We now report the initial experience with this novel technique.

Methods

A 3-year-old girl with PVT at 7 months after whole organ cadaveric liver transplant displayed portal hypertension with an episode of gastrointestinal bleeding, requiring a mesenteric-portal surgical shunt (“Rex shunt”) using a left internal jugular vein autograft.

Results

Upon current follow-up of 6 months, postoperative Doppler ultrasound confirmed shunt patency. Endoscopic status was significantly improved after surgery with resolution of portal hypertension. There was no recurrence of bleeding.

Conclusions

The mesenteric-portal shunt (“Rex shunt”), using a left internal jugular vein autograft, should be considered for children with late PVT after liver transplantation. Although this is an initial experience, we may conclude that this technique is feasible, with great potential benefits and low risks for these patients.     

A case of recurrent bilateral pneumonia with fever. Diagnosis: microscopic polyangiitis

Microscopic polyangiitis (MPA) is a rare systemic disease that usually presents as a pulmonary-renal syndrome. We describe 35-year-old men who presented with hemoptysis and bilateral alveolar opacities of the upper part of both lungs. The CT scan showed alveolar and round-glass opacities with a "mosaic-like" pattern. Bronchoalveolar lavage confirmed pulmonary hemorrhage. Renal biopsy was indicated because proteinuria revealed extracapillary glomerulonephritis. Laboratory tests showed a high level of serum antimyeloperoxidase-antineutrophil cytoplasmic antibody. We made a diagnosis of MPA. Cyclophosphamide and corticosteroid therapy was instituted and remission achieved. Through this case report, we discuss the diversity of the radio-clinical features of MPA.     

Use of a robotic arm to perform remote abdominal telesonography

OBJECTIVE: The purpose of this study was to design and validate a method of performing sonography between an expert center and an isolated site. A sonography probe is held on the patient by a robotic arm and remotely controlled from the expert's center. The robotic arm reproduces all the movements of the expert's dummy probe on the patient probe. The system was tested on 87 patients at our hospital. CONCLUSION: Robotic telesonography can be used for reliable diagnosis without moving the patient. No false diagnoses were made in this study. A bandwidth of 250 Kbps via integrated services digital network or satellite is required for reliable diagnosis. Such a system can provide diagnostic information that is currently unavailable in isolated or inaccessible areas and on rescue vehicles.     

Surgical exclusion of a symptomatic circumflex coronary to right atrium fistula

Coronary artery fistulas are rare and half of them are symptomatic. Diagnosis is confirmed by echocardiography and coronarography and can be precisely located by multislice CT-scan. We report the case of a 56-year-old female patient with congestive heart failure caused by a coronaro-cardiac fistula established between the proximal circumflex coronary artery and the right atrium. Surgical exclusion of the fistula was achieved by ligation of both extremities and a running suture on the aneurysmal vessel. Follow-up at 6 months was satisfactory with an asymptomatic patient and absence of recurrence of the fistula on echocardiography.     

Mycobacterium tuberculosis infection in allogeneic bone marrow transplantation patients.

Bone marrow transplant (BMT) recipients are prone to bacterial, viral and fungal infections. Mycobacterium tuberculosis infection can occur in these patients, but the incidence is lower than that of other infections. This report describes four patients with Mycobacterium tuberculosis infection identified from 641 adult patients who received a BMT over a 12-year period (prevalence 0.6%). The pre-transplant diagnosis was AML in two patients and CML in the other two. Pre-transplant conditioning consisted of BU/CY in three patients and CY/TBI in one. Graft-versus-host disease (GVHD) prophylaxis was MTX/CsA in three patients and T cell depletion of the graft in one patient. Sites of infection were lung (two), spine (one) and central nervous system (one). Onset of infection ranged from 120 days to 20 months post BMT. Two patients had co-existing CMV infection. One patient had graft failure. The two patients who received anti-tuberculous (TB) therapy recovered from the infection. Although the incidence of tuberculosis in BMT patients is not as high as in patients with solid organ transplants, late diagnosis due to the slow growth of the bacterium can lead to delay in instituting anti-TB therapy. A high index of suspicion should be maintained, particularly in endemic areas.