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BioMed Central Page 1 of 4 (page number not for citation purposes) Journal of Medical Case Reports Open Access Case report Bilateral sternoclavicular joint septic arthritis secondary to indwelling central venous catheter: a case report Charita Pradhan 1 , Nicholas FS Watson* 1 , Nitin Jagasia 2 , Ray Chari 2 and Jane E Patterson 1 Address: 1 Department of General Surgery, Kings Mill Hospital, Mansfield, UK and 2 Department of Orthopaedic Surgery, Kings Mill Hospital, Mansfield, UK Email: Charita Pradhan - charita74@yahoo.com; Nicholas FS Watson* - nicholas.watson@nottingham.ac.uk; Nitin Jagasia - nitinjagasia@hotmail.com; Ray Chari - chari.ray@sfh-tr.nhs.uk; Jane E Patterson - Jane.Patterson@sfh-tr.nhs.uk * Corresponding author Abstract Introduction: Septic arthritis of the sternoclavicular joint is rare, comprising approximately 0.5% to 1% of all joint infections. Predisposing causes include immunocompromising diseases such as diabetes, HIV infection, renal failure and intravenous drug abuse. Case presentation: We report a rare case of bilateral sternoclavicular joint septic arthritis in an elderly patient secondary to an indwelling right subclavian vein catheter. The insidious nature of the presentation is highlighted. We also review the literature regarding the epidemiology, investigation and methods of treatment of the condition. Conclusion: SCJ infections are rare, and require a high degree of clinical suspicion. Vague symptoms of neck and shoulder pain may cloud the initial diagnosis, as was the case in our patient. Surgical intervention is often required; however, our patient avoided major intervention and settled with parenteral antibiotics and washout of the joint. Introduction Septic arthritis of the sternoclavicular joint (SCJ) is rare, comprising approximately 0.5% to 1% of all joint infec- tions [1]. Infection tends to develop insidiously, and is frequently complicated by osteomyelitis. Predisposing causes include immunocompromising diseases such as diabetes, human immunodeficiency virus (HIV) infec- tion, renal failure and intravenous drug abuse. One of the rarer causes is catheterisation of the subclavian vein. Case presentation An 85-year-old man was admitted with a 3-week history of projectile vomiting, decreased appetite and halitosis. He was otherwise independent and had no medical comorbidities. On examination, he was observed to be cachectic and malnourished, with moderate renal impair- ment: urea 15.8 mg/dl; creatinine 197 μmol/l; white blood cell count (WBC) 9.1 × 10 9 /litre. A gastroscopy was performed, which diagnosed gastric outlet obstruction. Subsequent imaging by barium meal and computed tom- ography (CT) demonstrated a stricture in the second part of the duodenum due to a large fixed tumour, which was not considered amenable to curative surgical resection. As a result, the patient was scheduled for a palliative gastro- jejunostomy. Published: 29 April 2008 Journal of Medical Case Reports 2008, 2:131 doi:10.1186/1752-1947-2-131 Received: 2 November 2007 Accepted: 29 April 2008 This article is available from: http://www.jmedicalcasereports.com/content/2/1/131 © 2008 Pradhan et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Journal of Medical Case Reports 2008, 2:131 http://www.jmedicalcasereports.com/content/2/1/131 Page 2 of 4 (page number not for citation purposes) During the surgical procedure, a multilumen right subcla- vian central venous catheter (CVC; Vygon, Cirencester, UK) was inserted by the anaesthetist with full aseptic pre- cautions, using the Seldinger technique and under ultra- sound guidance. No apparent difficulty in insertion or periprocedural complication was noted. Following confir- mation of a satisfactory line RESTORING PATENCY TO CENTRAL VENOUS ACCESS DEVICES Indications Venous access is poor Intravenous therapy involves venous sclerosants Repeated sampling, or venesection Ambulatory chemotherapy given as an outpatient Prolonged intravenous chemotherapy and/or total parenteral nutrition (TPN), or for repeated administration of blood products Contraindications There is not absolute contraindications Thrombocytopenia and platelet dysfunction: The platelet count < 50·109/l The clotting factors abnormality: the INR > 1.5 Neutropenia : A neutrophil count < 1,000/µL • may have septic episodes Active infection • who require long-term antibiotic treatment, a temporary percutaneous CVA catheter or a peripherally inserted central venous catheter is preferable Choice of catheter • Short term use Nontunnelled catheter • Complex insertion and removal Skin-tunnelled catheter • Patient can swim, bath as normal Ports PICC • Don’t require platelet support and correction of clotting Choice of catheter Choice of catheter PICC PORTS Management of complications catheterrelated infection catheter malfunction catheter-related thrombosis Recombinant urokinase is safe and effective in restoring patency to occluded central venous access devices: a multiple-center, international trial • BACKGROUND: • The treatment of choice for central venous access device (CVAD) occlusion is intracatheter thrombolysis, which has been reported to reestablish patency in up to 80% of cases • OBJECTIVE: • This multiple-center, open-label study was performed to test the hypothesis that a new recombinant urokinase (r-UK, urokinase alfa) is safe and effective in reestablishing patency in a large unselected cohort of occluded CVADs • METHODS: • Pediatric and adult patients with any type of CVAD occlusion of any duration were treated with 5000 IU/mL intracatheter r-UK Lumen patency was assessed after 5, 15, and 30 mins; a second dose of r-UK was instilled if the catheter remained occluded after 30 mins • RESULTS: • A total of 903 r-UK instillations were performed in 878 patients (age range, 16 days to 96 yrs) Overall, instillation of r-UK successfully restored total catheter patency (all treated lumens) to 75% of CVADs (681 of 902) • Patency was restored to at least one occluded lumen in 79% of devices (712 of 902) • Patency was restored equally in catheters with total occlusion (76%) as in catheters with only withdrawal occlusion (75%) • The median +/- sd time to patency was 15 +/- 20.8 mins (range, 5-203 mins) • • • • • • • • • • • • • • Recombinant tissue plasminogen activator (alteplase) for restoration of function to occluded central venous catheters in pediatric patients Shen V1, Li X, Murdock M, Resnansky L, McCluskey ER, Semba CP; COOL Investigators PURPOSE: To evaluate the safety and efficacy of alteplase for restoring function to occluded central venous catheters in a pediatric population PATIENTS AND METHODS: A phase III, open-label, single-arm, multicenter trial was performed in 995 adult and pediatric patients with dysfunctional nondialysis catheters and ports and 18 years of age N = 122 Alteplase (2 mg/2 mL) 30 and 120 minutes Subjects weighing > or =30 kg received mL of alteplase; subjects 14 days duration, the efficacy was 91%, 78%, and 60%, respectively Success was independent of the patient's age, sex, body weight, CVC type, or catheter age There were no cases of death, ICH, major bleeding episodes, or embolic events attributable to treatment CONCLUSIONS: An alteplase regimen of up to two 2-mg doses is safe and effective for restoration of function to occluded central venous catheters in a pediatric population Thrombolytic therapy for central venous catheter occlusion Design and Methods Efficacy of thrombolytic therapy, central venous catheter clearance rates and time to clearance were assessed Results 100% 90% 80% 70% 60% 50% dose 40% dose 30% 20% 10% 0% alteplase reteplase tenecteplase urokinase alfimenprase Conclusions Thrombolytic agents successfully clear central venous catheter occlusions in most cases Newer agents may act more rapidly and effectively than currently utilized therapies, but randomized studies with direct comparisons of these agents are needed to determine optimal management for catheter obstruction • • • • • • • • • • • • • Alteplase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm ...In-vivo evaluation of simultaneous administration of incompatible drugs in a central venous catheter with a decreased port to port distance Gerardo Reyes, Gurpreet S Mander, Tarek S Husayni, Rabi F Sulayman and David G Jaimovich Background: Multilumen catheters are commonly used in critically ill children. Their use, however, is associated with significant morbidity. We studied the simultaneous administration of incompatible drugs using a new triple-lumen catheter with decreased length and port to port distances. Methods: Ten domestic swine, 10–20kg in weight, were divided into two groups of five. Total parenteral nutrition was administered through the distal port and phenytoin was administered as a bolus and as an infusion in each group. Samples were taken from two sites during the bolus and at 1, 5, and 15min during phenytoin infusion. Histograms were generated for particle size and concentration. Samples were also examined under the microscope for particles. Results: Histograms of particle size did not show any alteration of the histogram that would suggest particle size >2µm in diameter in the study or control samples. No particles were identified by phase microscope, light microscope, or Wright stain smear. Conclusions: The use of a triple-lumen catheter with a distance of 0.4cm between the proximal port and the medial port and 1.3cm between the medial port and the distal port, for the in vivo simultaneous administration of incompatible solutions does not result in precipitates large enough to cause adverse clinical effects. Addresses: Hope Children’s Hospital, Division of Critical Care, Oak Lawn, Illinois, USA; The University of Illinois at Chicago, School of Medicine, Chicago, Illinois, USA. Correspondence: Gerardo Reyes, MD, FCCM, Hope Children’s Hospital, Director, Critical Care Training, 4440 West 95th Street, Oak Lawn, IL 60453-2699, USA. Tel: 708 346 5685; fax: 708 346 4714; e mail: gerardo.reyes@advocatehealth.com Supported, in part, by a grant from Arrow International, Reading, Pennsylvania, USA Keywords: catheter, drugs, pediatrics Received: 10 November 1997 Revisions requested: 22 January 1998 Revisions received: 20 May 1998 Accepted: 3 June 1998 Published: XX Month 199X Crit Care 1999, 3:51–53 The original version of this paper is the electronic version which can be seen on the Internet (http://ccfporum.com). The electronic version may contain additional information to that appearing in the paper version. © Current Science Ltd ISSN 1364-8535 Research paper 51 Introduction A multilumen central venous catheter is the preferred vas- cular access route for critically ill patients requiring multi- ple drug infusions, parenteral hyperalimentation, and other potentially incompatible drugs [1]. The complexity of delivering these substances becomes more difficult when the size and length of the catheter is limited, as in the pediatric population. A previous study has shown that in vivo simultaneous intravenous infusion of physically incompatible substances through a commercially available multiple lumen intravenous catheter, double-lumen peripheral venous catheter (IV-01100, Arrow Interna- tional, Reading, Pennsylvania, USA) did not cause precip- itation in the vascular system or other adverse clinical effects [2]. This study looked at a modified 5.5F×5cm, triple-lumen catheter with a port distance of 0.4cm between the medial and proximal ports and 1.3cm between the distal and medial ports (Arrow International), with a total distance of 1.7cm between the distal port and the proximal port, to assess if decreased port spacing between lumens causes precipitation when incompatible intravenous solutions are administered simultaneously. Materials and methods Ten domestic swine weighing 10–20kg were anesthetized with ketamine 10mg/kg intramuscularly, atropine 0.01mg/kg intravenously, and isoflurane for continuous anesthesia. The trachea was intubated with a #5 or #6 uncuffed endotracheal tube and controlled ventilation was 56 Critical Care February 2004 Vol 8 No 1 Macduff and Grant We read with interest the article by Singh and coworkers [1] describing the use of central venous catheters to drain pleural effusions. We agree that the use of small-bore catheters has a number of advantages compared with repeated thoracocentesis or the use of traditional large-bore drains inserted by blunt dissection. Indeed, recent guidelines [2] support the use of smaller bore tubes (8–14 Fr; except for haemothorax) in both pleural effusions and pneumothorax. However, we have reservations regarding the routine use of central venous catheters to drain pleural effusions. Several manufacturers (including the Sims-Portex Seldinger Chest Drainage Kit and Cook Quick-Thal Chest Tube) have specific chest drainage systems that take advantage of the Seldinger dilator over a wire method of insertion. These have the advantage of having a number of side ports (two to four), which reduces the possibility of blockage by debris, and they are available in a range of sizes (8–36 Fr). While we applaud innovation, in today’s medico-legal climate it is surely wiser to use specifically designed equipment if it is available. References 1. Singh K, Loo S, Bellom R: Pleural drainage using central venous catheters. Crit Care 2003, 7:R191-R194. 2. Laws D, Neville E, Duffy J, on behalf of the British Thoracic Society Pleural Disease Group: BTS guidelines on the insertion of a chest drain. Thorax 2003, Suppl II:ii53-ii59. Letter Should central venous catheters be used to drain pleural effusions? Andrew MacDuff 1 and Ian S Grant 2 1 Locum Registrar Respiratory Medicine, Western General Hospital, Edinburgh, Scotland 2 Consultant Intensive Care Medicine, Western General Hospital, Edinburgh, Scotland Correspondence: Ian S Grant, is.grant@luht.scot.nhs.uk Published online: 2 January 2004 Critical Care 2004, 8:56 (DOI 10.1186/cc2447) This article is online at http://ccforum.com/content/8/1/56 © 2004 BioMed Central Ltd (Print ISSN 1364-8535; Online ISSN 1466-609X) 57 Available online http://ccforum.com/content/8/1/57 We would like to thank MacDuff and Grant [1], as well as the many others who accessed it, for their interest in our article [2] on using central venous catheters for pleural drainage. We started using this technique about 5 years ago with the aim of achieving better patient comfort without compromising on adequate pleural drainage. We did not at that time have access to the specific chest drainage systems mentioned by MacDuff and Grant. While we agree that the central venous catheters we describe are not specifically designed for the purpose of pleural drainage, they are made of biologically inert materials with a long track record of intravenous use. We have not modified them before placement. To minimize the risk of complications at insertion, we were selective in our choice of patients and we monitor these patients closely from the safety and efficacy points of view. We share MacDuff and Grant’s views on the need to practice safely in the current medico-legal climate. Our management is frequently influenced by the need to be seen to be medico-legally correct. This, however, has probably resulted in the increased per-patient care cost. We find this to be especially true in the use of specially designed equipment whose usage levels are fairly low. In the case of the two catheter systems mentioned by MacDuff and Grant, the prices quoted in Singapore are between eight and 10 times higher than the cost of the single lumen central lines described. We intuitively agree that these catheters with the multiple drainage lumens have a lower risk of catheter blockage compared with the central venous catheters. We are not, however, aware of any published literature that ascertains this. We have not experienced any catheter blockage with the catheters we use despite seeing fibrinous material in the drainage bag. We have been caught by surprise at the number of readers who accessed this article, perhaps because this is an Open Access article. A number of these readers may work in financially stretched healthcare systems. We hope that by sharing our experience this technique may prove useful when it is difficult to procure specially designed sets, either because they are expensive or because they are not readily available. We caution readers, however, to select their patients carefully and to monitor the efficacy of the placement of these catheters. We do not advocate using this technique for the drainage of haemothoraces or empyemas. References 1 MacDuff A, Grant IS: Should central venous catheters be used to drain pleural effusions? Crit Care 2004, 8:56. 2 Singh K, Shi L, Bellomo R: Pleural drainage using central venous catheters. Crit Care 2003, 7:R191-R194. Letter Should central venous catheters be used to drain pleural effusions? Authors’ response Kulgit Singh 1 , Shi Loo 2 and Rinaldo Bellomo 3 1 Consultant, Department of Anaesthesiology, Tan Tock Seng Hospital, Singapore 2 Senior Consultant, Department of Anaesthesiology, Tan Tock Seng Hospital, Singapore 3 Professor of Medicine, University of Melbourne, Director of Intensive Care Research, Department of Intensive Care, Austin & Repatriation Medical Centre, Heidelberg, Melbourne, Victoria, Australia Correspondence: Kulgit Singh, Kulgit_singh@ttsh.com.sg Published online: 2 January 2004 Critical Care 2004, 8:57 (DOI 10.1186/cc2448) This article is online at http://ccforum.com/content/8/1/57 © 2004 BioMed Central Ltd (Print ISSN 1364-8535; Online ISSN 1466-609X) Page 1 of 2 (page number not for citation purposes) Available online http://ccforum.com/content/10/6/181 Abstract Measurements of central venous oxygen saturation (ScvO 2 ) have been successfully used to guide haemodynamic therapy in critical care. The efficacy of this approach in the treatment of severe sepsis and septic shock has stimulated interest in the use of ScvO 2 to guide management in patients undergoing major surgery. The physiological basis of ScvO 2 measurement is complex. A number of outstanding issues will need to be resolved before incorporating ScvO 2 measurement into routine practice. First, it is not yet clear which value of ScvO 2 should be targeted. Second, there is some uncertainty as to which interventions are the most effective for achieving the desired value of ScvO 2 or how long this value should be maintained. The study by The Collaborative Study Group on Perioperative ScvO 2 Monitoring published in this edition of Critical Care may help provide answers to some of these questions. Our understanding of ScvO 2 measurement remains limited, however, and the routine use of peri-operative ScvO 2 - guided goal-directed therapy cannot be recommended until a large randomised trial has confirmed the value of this approach. The use of central venous saturation (ScvO 2 ) to guide haemo- dynamic management is an important and evolving aspect of clinical practice. An observational study [1] published in this issue of Critical Care has advanced our understanding of this form of monitoring by exploring the association between derangements in ScvO 2 and complication rates after major abdominal surgery. This study provides a detailed description of peri-operative trends in ScvO 2 and confirms the findings of previous work which suggests that reductions in ScvO 2 are associated with increased post-operative complication rates [2]. Although the study is relatively small, the robust multi- centre approach and consistency with previous work support the applicability of the findings. The comparative simplicity of ScvO 2 measurement makes this an attractive technique. With the blood gas analysis technology available in most institutions, intermittent ScvO 2 monitoring can be performed in any patient with a central venous catheter. However, it is not yet clear whether ScvO 2 measurement through intermittent blood sampling is an adequate alternative to continuous monitoring with a fibre- optic catheter. Interest in ScvO 2 measurement is not new, and several reports have explored the physiology and clinical significance of this parameter over the past 50 years [3]. Of these, the work of Rivers and colleagues [4] has proved the most influential. These authors used a ScvO 2 value of 70% as a target for goal-directed haemodynamic therapy (GDT) in patients presenting to hospital with severe sepsis and septic shock. They demonstrated that it may be possible to achieve substantial mortality reductions without the need for complex or invasive cardiac output monitoring technology. The success of Rivers’ work and several trials of peri-operative GDT indicates that the use of ScvO 2 as a haemodynamic goal may be equally valuable in surgical patients [5-8]. However, several questions must be considered before embarking on an interventional trial of ScvO 2 -guided peri- operative GDT. First, what treatments should be used to achieve the target value for ScvO 2 ? Second, which target value is most appropriate? Finally, how long should the target value be maintained? The study by the Collaborative Study Group (CSG) is important because it sets out to address some of these key questions. The value of ScvO 2 in any given patient reflects not only oxygen delivery but also oxygen consumption. Reductions in ScvO 2 may therefore reflect a large number of acute changes in physiology including hypoxia, shivering, anaesthesia, haemorrhage and myocardial ischaemia [3]. The therapeutic approach to achieving the target value may need to include more ... safe and effective in restoring patency to occluded central venous access devices: a multiple-center, international trial • BACKGROUND: • The treatment of choice for central venous access device... (age range, 16 days to 96 yrs) Overall, instillation of r-UK successfully restored total catheter patency (all treated lumens) to 75% of CVADs (681 of 902) • Patency was restored to at least one... in 79% of devices (712 of 902) • Patency was restored equally in catheters with total occlusion (76%) as in catheters with only withdrawal occlusion (75%) • The median +/- sd time to patency was