Health Education and Nursing Needs of Breast Cancer Patients With Totally Implantable Venous Access Ports at Different Stages.

Context: The totally implantable venous access port (TIVAP) is an intravenous-infusion device, with a lower complication rate than other such devices. If patients fail to maintain the catheter, however, complications can still occur. Patients' needs may vary by the period of the port's use. Objective: The study intended to explore the differences in the needs of breast-cancer (BC) patients with TIVAPs for health education and nursing care at different periods of the port's use and to determine the kinds of targeted health education that can improve patients' quality of life. Design: The research team designed a questionnaire that the participants completed. Setting: The study took place at the Breast Center at the Fourth Hospital of Hebei Medical University in Shijiazhuang, China. Participants: Participants were 442 BC patients at the hospital between March and June 2020, who had TIVAPs at different stages. Groups: The study included three groups: (1) the preoperative group-participants in the preoperative period prior to the TIVAP implantation after they had signed a consent; (2) the chemotherapy group-participants in the chemotherapy period during the TIVAP's use for chemotherapy-agent transfusion, and (3) the maintenance group-participants in the maintenance period during which the TIVAD was in place but wasn't being used. Outcome Measures: The research team analyzed the results from the questionnaires, categorizing them as: (1) methods of knowledge acquisition, (2) methods of distribution of knowledge, (3) needs of participants in the different groups, and (4) distribution of symptoms among the groups. Results: Compared to other methods, the nursing staff was the main source that participants used to access the TIVAP-related information at different periods: preoperative group (79.6%), chemotherapy group (90.7%), and maintenance group (90.2%).The differences between the periods were statistically significant (P = .00). A traditional mode of education-the medical staff's explanations-was the most common in all groups: preoperative group (79.6%), chemotherapy group (83.3%), and (3) maintenance group (80.7%). Patients wanted new modes of receiving information: talks, a poster, and a medical system. TIVAP patients paid different amounts of attention to educational contents at the different stages (χ2 = 29.816, P = .00). Conclusions: BC patients' needs for health education and nursing vary at different stages when using TIVAPs. Nurses are the main source of knowledge about TIVAP in different periods for BC patients, and the nurses should obtain multidisciplinary health knowledge to enhance the benefits of the education for patients. The current education for patient is traditional, and hospitals need to implement new modes of education such as medical systems and network platforms, lectures, and posters for health education.

[Prevention from PICC-related venous thrombosis in the upper limbs of malignant tumor patients with moxibustion combined with plucking at Jiquan (HT 1): a randomized controlled trial].

OBJECTIVE: To observe the clinical effect of moxibustion combined with plucking technique at Jiquan (HT 1) for preventing peripherally inserted central catheter (PICC)-related venous thrombosis in the upper limbs of malignant tumor patients. METHODS: A total of 80 malignant tumor patients undergoing PICC were randomized into an observation group and a control group, 40 cases in each one. In the control group, the routine care for PICC was exerted. In the observation group, besides the routine care, moxibustion combined with plucking technique at Jiquan (HT 1) was added. Mild moxibustion was exerted along the venous distribution of PICC (avoiding the entry site) for 10 to 15 min, and then, the circling moxibustion was applied to Quchi (LI 11), Xuehai (SP 10) and Tianfu (LU 3), 3 to 5 min at each acupoint. Finally, plucking technique was given at Jiquan (HT 1) for 5 to 10 min. This combined therapy was intervened since the 2nd day of PICC placement, once daily, 5 times a week, for 3 weeks totally. The incidence of the PICC-related venous thrombosis in the upper limbs was compared between the two groups on day 42 of placement. On day 2, 7, 14, 21, 28, 35 and 42 of PICC placement, the peak systolic velocity (PSV) and the end-diastolic velocity (EDV) of the subclavicular vein on the placement side were observed separately in the two groups. RESULTS: The incidence of the PICC-related venous thrombosis in the upper limbs in the observation group was lower than that in the control group (2.5% [1/40] vs 17.5% [7/40], P<0.05). From day 7 to 35 of PICC placement, PSV of the subclavicular vein on the placement side was higher than that on the day 2 of PICC placement in the observation group (P<0.05). On day 28 and 42 of PICC placement, PSV of the subclavicular vein on the placement side was lower than that on the day 2 of PICC placement in the control group (P<0.05). In the observation group, EDV of the subclavicular vein on the placement side was higher than that on the day 2 of PICC placement from day 7 to 28 of PICC placement (P<0.05). In the control group, EDV of the subclavicular vein on the placement side from day 28 to 42 of PICC placement was lower than that on the day 2 of PICC placement (P<0.05). From day 7 to 42 of PICC placement, PSV and EDV of the subclavicular vein on the placement side in the observation group were all higher than those in the control group (P<0.01, P<0.05). CONCLUSION: The combined treatment of moxibustion with plucking technique at Jiquan (HT 1) can effectively prevent PICC-related venous thrombosis in the upper limbs and improve venous blood flow velocity in malignant tumor patients.

Diagnostic challenges with central venous catheter studies.

A central venous catheter is typically made of silicone rubber or polyurethane and inserted into a large central vein to provide prolonged and direct access to central venous circulation. These catheters provide a safe and effective method to administer intravenous medications, nutritional supplements, fluids and blood products. However, a myriad of complications is associated with central venous catheters, including, but not limited to, mechanical malfunction or fracture, kinking, erroneous placement, line infection, fibrin sheath formation and venous thrombosis. Following clinical and radiographic evaluation, contrast-enhanced line studies constitute the next best diagnostic tool to assess the functionality of central venous catheters. However, there is a lack of standardization in the literature outlining how these studies should be performed. In addition, the interpretation of these studies can be problematic for general pediatric radiologists, many of whom are often not familiar with placement or manipulation of these catheters. In this pictorial review, we highlight the challenges associated with performing and interpreting fluoroscopically guided contrast injection studies, using case studies drawn from a large tertiary children's hospital database for illustration. Revealing these challenges and understanding their causative mechanisms can improve the performance of these line studies.

New safer management for breast cancer patients who need neoadjuvant therapy during SARS-COVID pandemic.

During the first hit of SARS-COVID pandemic, an important reorganization of Healthcare Services has been done, and new protocols and pathways to protect frail patients like oncological patients were designed. The second hit of pandemic had stressed these new pathways and suggests to health-workers some improvements for safer management of patents.We reported our experience in organizing the clinical pathway of neoadjuvant therapy candidate patients based on the execution of sentinel lympho-node biopsy and the placement of implantable venous access port in the same access to operating room before neoadjuvant chemotherapy suggesting a possible organizational model. In the period October-December 2020 we have included in this new type of path twelve patients and we have not registered any cases of COVID among the patients included. We think this new path, adopted amid the second hit, will be useful for all Breast Units that are facing the challenge of guaranteeing the highest standards of care in a historical moment where the health emergency occupies the efforts of health workers and the economic resources of health systems.

Prevention from PICC-related venous thrombosis in the upper limbs of malignant tumor patients with moxibustion combined with plucking at Jiquan (HT 1): a randomized controlled trial / 中国针灸

OBJECTIVE@#To observe the clinical effect of moxibustion combined with plucking technique at Jiquan (HT 1) for preventing peripherally inserted central catheter (PICC)-related venous thrombosis in the upper limbs of malignant tumor patients.@*METHODS@#A total of 80 malignant tumor patients undergoing PICC were randomized into an observation group and a control group, 40 cases in each one. In the control group, the routine care for PICC was exerted. In the observation group, besides the routine care, moxibustion combined with plucking technique at Jiquan (HT 1) was added. Mild moxibustion was exerted along the venous distribution of PICC (avoiding the entry site) for 10 to 15 min, and then, the circling moxibustion was applied to Quchi (LI 11), Xuehai (SP 10) and Tianfu (LU 3), 3 to 5 min at each acupoint. Finally, plucking technique was given at Jiquan (HT 1) for 5 to 10 min. This combined therapy was intervened since the 2nd day of PICC placement, once daily, 5 times a week, for 3 weeks totally. The incidence of the PICC-related venous thrombosis in the upper limbs was compared between the two groups on day 42 of placement. On day 2, 7, 14, 21, 28, 35 and 42 of PICC placement, the peak systolic velocity (PSV) and the end-diastolic velocity (EDV) of the subclavicular vein on the placement side were observed separately in the two groups.@*RESULTS@#The incidence of the PICC-related venous thrombosis in the upper limbs in the observation group was lower than that in the control group (2.5% [1/40] vs 17.5% [7/40], P<0.05). From day 7 to 35 of PICC placement, PSV of the subclavicular vein on the placement side was higher than that on the day 2 of PICC placement in the observation group (P<0.05). On day 28 and 42 of PICC placement, PSV of the subclavicular vein on the placement side was lower than that on the day 2 of PICC placement in the control group (P<0.05). In the observation group, EDV of the subclavicular vein on the placement side was higher than that on the day 2 of PICC placement from day 7 to 28 of PICC placement (P<0.05). In the control group, EDV of the subclavicular vein on the placement side from day 28 to 42 of PICC placement was lower than that on the day 2 of PICC placement (P<0.05). From day 7 to 42 of PICC placement, PSV and EDV of the subclavicular vein on the placement side in the observation group were all higher than those in the control group (P<0.01, P<0.05).@*CONCLUSION@#The combined treatment of moxibustion with plucking technique at Jiquan (HT 1) can effectively prevent PICC-related venous thrombosis in the upper limbs and improve venous blood flow velocity in malignant tumor patients.

Use of hypnosis for the placement of a midline catheter in a patient at the end of life.

OBJECTIVE: The case of a non-oncological patient at the end of his life, admitted to a Palliative Care Unit (PCU), is presented. After a failed attempt to place a central venous catheter (CVC) and another placement of a peripherally inserted central catheter (PICC), the patient exhibited high anxiety regarding a midline catheter (MC) and refused its placement, even though this was necessary for the administration of intravenous drugs to control dyspnea and other complex symptoms that he presented. METHOD: An intervention through clinical hypnosis for successful MC placement and symptom control is described. RESULT: Through clinical hypnosis and interdisciplinary teamwork, it was possible to place a MC, necessary for symptomatic control of a complex patient. SIGNIFICANCE OF RESULT: This case exemplifies hypnosis as a simple procedure that is easy to apply, accepted by the patient, and effective in the implementation of invasive procedures and symptom control in PCUs.

The anticoagulants rivaroxaban and low molecular weight heparin prevent PICC-related upper extremity venous thrombosis in cancer patients.

Peripherally inserted central catheter (PICC) is often applied in chemotherapy patients and commonly causes upper extremity venous thrombosis (UEVT), which should be prevented.To assess the preventive effects of the anticoagulants rivaroxaban and low molecular weight heparin (LMWH) on UEVT in patients receiving chemotherapy through PICCs.A total of 423 chemotherapy patients with continuous PICC use between January 2014 and June 2015 at the Oncology Department of Dongying People's Hospital were divided into 3 groups: rivaroxaban (10 mg/day, orally), LMWH (Enoxaparine, 4000 anti-Xa IU/day, subcutaneous injection), and control (no anticoagulant). UEVT incidence and other complications during PICC use were observed and recorded.The rivaroxaban, LMWH, and control groups included 138 (79 males; 54.9 ±â€Š11.0 years), 144 (76 males; 56.0 ±â€Š10.9 years), and 141 (71 males; 53.3 ±â€Š10.9 years) patients, (P = .402 and P = .623 for age and sex respectively). There were no differences in cancer location (P = .628), PICC implantation site (P > .05), body mass index (BMI) (P = .434), blood pressure (all P > .05), blood lipids (5 laboratory parameters included, all P > .5), smoking (P = .138), history of lower limb venous thrombosis (P = .082), and 10 other associated comorbidities (all P > .5). Twenty-nine patients withdrew from the study (5 from the rivaroxaban, 12 from the LMWH, and 12 from the control groups, respectively), and 394 patients were analyzed. There were significant differences in the rivaroxaban group and the LMWH group compared to the control group (P = .010 and P = .009, respectively), but no significant difference was observed between the rivaroxaban group and the LMWH group (P = .743).Anticoagulants such as rivaroxaban and LMWH may reduce the incidence of PICC-related UEVT in patients receiving chemotherapy.

Effect of Inhalation Aromatherapy on Procedural Pain and Anxiety After Needle Insertion Into an Implantable Central Venous Port Catheter: A Quasi-Randomized Controlled Pilot Study.

BACKGROUND: Needle insertion into an implantable central venous port catheter may lead to procedural pain and anxiety in cancer patients. OBJECTIVE: The aim of this study was to determine the effects of inhalation aromatherapy on procedural pain and anxiety after needle insertion into an implantable central venous port catheter. METHODS: This study included 123 cancer patients who were scheduled to undergo chemotherapy. Patients were randomly assigned to either the lavender group (n = 41), the eucalyptus group (n = 41), or a control group (n = 41). Participants in the intervention groups inhaled 3 drops of essential oil for 3 minutes before needle insertion into an implantable venous port catheter. Patients in the control group received no intervention before needle insertion. Data were collected using the visual analog scale (VAS) and State Anxiety Inventory. RESULTS: The average VAS scores of the lavender group were significantly lower than those of the control group (P < .05). There were no significant differences in the average VAS scores between the eucalyptus group and the control group (P > .05). In addition, the average State Anxiety Inventory scores of the lavender group, the eucalyptus group, and the control group were not significantly different (P > .05). CONCLUSION: Inhalation aromatherapy with lavender may be an effective technique to relieve pain related to needle insertion into an implantable central venous port catheter. IMPLICATIONS FOR PRACTICE: Inhalation aromatherapy with lavender oil may be useful in the management of procedural pain levels during needle procedure. However, further randomized controlled trials are needed to validate this study.

Hypnosis as adjunct therapy to conscious sedation for venous access device implantation in breast cancer: A pilot study.

BACKGROUND: Recent reviews support that hypnosis has great potential for reducing pain and anxiety during mini-invasive surgery. Here, we assessed the feasibility of hypnotic induction session as adjunct therapy in conscious sedation for venous access device implantation. Primary outcomes were safety and patient satisfaction. METHODS: Thirty consecutive women with breast cancer were proposed adjunct of hypnosis before implantation under conscious sedation (midazolam: 0.5 mg ± bolus of Ketamin: 5 mg on demand) indicated for chemotherapy. Self-hypnosis was programmed and guided by one of two trained anesthesiologists. Implantation was performed by one of two experimented surgeons. It consisted of blind subclavian implantation of Braun ST 305 devices using a percutaneous technique adapted from Selinger's procedure. Clinical data were prospectively collected and retrospectively analyzed. A comprehensive custom-made questionnaire recorded patient satisfaction. RESULTS: In all, 30/30 patients consented to the procedure. The median age was 54 years (range: 35-77 years). The primary procedure was successful in 29/30. One case was converted into internal jugular vein access after a first attempt. Median length time of the implantation procedure in the operative room was 20 min (range: 10-60 min). Median length time in the recovery room preceding home discharge was 65 min (range: 15-185 min). None of the patients suffered complications. The satisfaction rate was ≥90%, 27/30 patients would get hypnosis in case of reimplantation if necessary and 27/30 would recommend this procedure to others. CONCLUSION: Hypnosis under conscious sedation appears feasible and safe for port implantation under conscious sedation in cancer patients. Further studies would determine the exact value of hypnosis effectiveness.

Systematic review of antimicrobial lock therapy for prevention of central-line-associated bloodstream infections in adult and pediatric cancer patients.

BACKGROUND: Central venous catheter (CVC) use is commonplace in cancer patients. Antimicrobial lock therapy (ALT), the instillation of a concentrated antimicrobial solution into the catheter lumen, is one method for preventing infection among CVCs. This systematic review discusses the effectiveness and safety of prophylactic ALT in cancer patients with CVCs. METHODS: A literature search was performed using the Medline database and Google Scholar from inception until April 2016. The following terms were used: 'antimicrobial lock solution', 'antibiotic lock solution', 'oncology', 'hematology', 'pediatrics', 'prevention', 'cancer', 'catheter related bloodstream infections', 'central-line associated bloodstream infection' (CLABSI) and 'central venous catheter'. Studies evaluating prophylactic ALT in cancer patients alone were eligible for inclusion. Case reports, case series and in-vitro studies were excluded. RESULTS: In total, 78 articles were identified. Following all exclusions, 13 articles (three adult and 10 pediatric) were selected for evaluation. The most common agents utilized were vancomycin with heparin; ethanol; taurolidine; and minocycline with EDTA. Quality of evidence was moderate to high in adult studies and low to moderate in pediatric studies. Use of ALT decreased the incidence of CLABSI in the majority of studies; however, there were significant differences in definitions of CVC-related infection, dwell times and lock solutions. CONCLUSION: Lock therapy may be an adjunct in high-risk cancer patients for the prevention of CLABSI; higher quality evidence is needed for specific ALT recommendations.

The effect of intraumbilical fetal nutrition via a subcutaneously implanted port system on amino acid concentration by severe IUGR human fetuses.

OBJECTIVE: To determine if intrauterine intraumbilical supplementation with amino acids (AA) and glucose can improve neonatal outcome of severe growth restricted human fetuses (IUGR). METHODS: Prospective pilot study of intrauterine treatment of severe IUGR fetuses [n=14, 27 weeks of gestation (range 23-31)] with cerebroplacental ratio <1, with long-term intraumbilical AA and glucose supplementation (10% of feto-placental blood volume/day) using a perinatal port system alone (n=5) or combined with hyperbaric oxygenation (n=1, HBO) vs. control group (n=8). RESULTS: The duration of continuous intraumbilical AA/glucose supplementation was 11 (6-13) days. Daily intravascular fetal nutrition significantly prolonged the brain sparing to delivery interval by 24 (14-33) days vs. 5.6 (2-12) days in controls. Fetal nutrition reduced blood flow resistance in the placental circulation but did not affect the Doppler profile of cerebral arteries. Higher weight gain of 113.5 (36-539) g was observed following supplementation compared to 33.3 (8-98) g in the control group (P<0.05). In spite of this, fetuses below 28 weeks of gestation did not sufficiently benefit from infused commercial AA. We found a reduced fetal plasma concentration of the essential AA histidine, threonine, lysine and arginine, and non-essential AA taurine, in severe IUGR fetuses in both groups. Long-term supplementation with a commercial AA formula led to a slight, but not significant, reduction of histidine, threonine, lysine, arginine, asparagine and glutamine. However, the concentration of tryptophan and glutamic acid slightly increased. HBO can be combined with AA supplementation via a port system. In one case, the port system was also successfully used for fetal blood transfusion. CONCLUSIONS: Intravascular treatment of IUGR with fetal nutrition can prolong pregnancy with severe placental insufficiency and brain sparing for many weeks. However, rather than normalizing AA concentrations, an enhanced AA imbalance was observed in IUGR fetuses following supplementation. These deviations in AA concentrations prevent the recommendation for use of commercial AA solutions for prenatal treatment of extreme preterm IUGR fetuses.

Mitigation of Ventilator-induced Diaphragm Atrophy by Transvenous Phrenic Nerve Stimulation.

RATIONALE: Ventilator-induced diaphragm dysfunction is a significant contributor to weaning difficulty in ventilated critically ill patients. It has been hypothesized that electrically pacing the diaphragm during mechanical ventilation could reduce diaphragm dysfunction. OBJECTIVES: We tested a novel, central line catheter-based, transvenous phrenic nerve pacing therapy for protecting the diaphragm in sedated and ventilated pigs. METHODS: Eighteen Yorkshire pigs were studied. Six pigs were sedated and mechanically ventilated for 2.5 days with pacing on alternate breaths at intensities that reduced the ventilator pressure-time product by 20-30%. Six matched subjects were similarly sedated and ventilated but were not paced. Six pigs served as never-ventilated, never-paced control animals. MEASUREMENTS AND MAIN RESULTS: Cumulative duration of pacing therapy ranged from 19.7 to 35.7 hours. Diaphragm thickness assessed by ultrasound and normalized to initial value showed a significant decline in ventilated-not paced but not in ventilated-paced subjects (0.84 [interquartile range (IQR), 0.78-0.89] vs. 1.10 [IQR, 1.02-1.24]; P = 0.001). Compared with control animals (24.6 µm2/kg; IQR, 21.6-26.0), median myofiber cross-sectional areas normalized to weight and sarcomere length were significantly smaller in the ventilated-not paced (17.9 µm2/kg; IQR, 15.3-23.7; P = 0.005) but not in the ventilated-paced group (24.9 µm2/kg; IQR, 16.6-27.3; P = 0.351). After 60 hours of mechanical ventilation all six ventilated-paced subjects tolerated 8 minutes of intense phrenic stimulation, whereas three of six ventilated-not paced subjects did not (P = 0.055). There was a nonsignificant decrease in diaphragm tetanic force production over the experiment in the ventilated-paced and ventilated-not paced groups. CONCLUSIONS: These results suggest that early transvenous phrenic nerve pacing may mitigate ventilator-induced diaphragm dysfunction.

Holistic ultrasound in trauma: An update.

Holistic ultrasound is a total body examination using an ultrasound device aiming to achieve immediate patient care and decision making. In the setting of trauma, it is one of the most fundamental components of care of the injured patients. Ground-breaking imaging software allows physicians to examine various organs thoroughly, recognize imaging signs early, and potentially foresee the onset or the possible outcome of certain types of injuries. Holistic ultrasound can be performed on a routine basis at the bedside of the patients, at admission and during the perioperative period. Trauma care physicians should be aware of the diagnostic and guidance benefits of ultrasound and should receive appropriate training for the optimal management of their patients. In this paper, the findings of holistic ultrasound in trauma patients are presented, with emphasis on the lungs, heart, cerebral circulation, abdomen, and airway. Additionally, the benefits of ultrasound imaging in interventional anaesthesia techniques such as ultrasound-guided peripheral nerve blocks and central vein catheterization are described.

A Cross-Sectional Study of Patients' Satisfaction With Totally Implanted Access Ports.

BACKGROUND: Totally implanted access ports (PACs) are valuable tools for the treatment of patients with cancer because they ease the administration of chemotherapy, stem cells, and supportive care by reducing the rate of peripheral vein punctures. OBJECTIVES: The purpose of this study was to evaluate the satisfaction and impairments of activities of daily living of ambulatory patients with PAC systems receiving chemotherapy. METHODS: This cross-sectional, questionnaire-based study evaluated 202 patients with PAC systems in a comprehensive cancer center and cancer rehabilitation center. From November 2012 to August 2013, patients were invited to answer a questionnaire concerning quality of life and satisfaction with their PAC devices. Data regarding PAC-related complications were collected retrospectively by searching patients' medical history. FINDINGS: A total of 202 patients with 230 PAC devices were included. Median time from PAC implantation to inclusion in the study was nine months. Surgical complications occurred in some cases, with bleeding and hematoma being the most frequently observed events. Late complications consisted of infections, drug extravasation, PAC malposition, PAC malfunction, and thrombosis. A third of the patients reported that their PAC interfered with activities of daily living. However, most agreed that PAC systems alleviated the burden of chemotherapy administration, and the vast majority said they would choose the implantation of a PAC system for chemotherapy administration again.

Ultrasonography-guided central venous port placement with subclavian vein access in pediatric oncology patients.

BACKGROUND/PURPOSE: To evaluate the technical success and complications of image-guided central venous port (CVP) placement with subclavian vein (SCV) access in pediatric oncology population. MATERIALS AND METHODS: Ninety-two children (52 boys, 40 girls; mean age, 8.5 years) underwent CVP implantation under local anesthesia with conscious sedation. SCV access was firstly attempted under ultrasonographic guidance and CVP implantation was performed under fluoroscopic guidance. Technical success, peri-procedural (<24h) complication, and post-procedural (>24h) complication were assessed. RESULTS: In total, 102 CVPs were implanted in 92 children with a mean catheter time of 364 days (total, 38,224 days; range, 14-1911 days). In three small children, conversion of SCV access to internal jugular vein access yielded a primary technical success rate of 97.1% and overall technical success rate of 100%. Three minor peri-procedural complications were observed (2.9%) and seven post-procedural infectious complications occurred (infection rate, 6.7%; 0.18/1000 catheter days). No pneumothorax, catheter malposition, venous thrombosis, or mortality occurred. CONCLUSION: Image-guided CVP placement with SCV access in a pediatric population was performed with high technical success and low complication rate without general anesthesia. This procedure can be taken into account as a choice of procedure when internal jugular venous access is not possible.

Emergency physician perspectives on central venous catheterization in the emergency department: a survey-based study.

OBJECTIVES: The objective was to assess clinician experience, training, and attitudes toward central venous catheterization (CVC) in adult emergency department (ED) patients in a health system promoting increased utilization of CVC for severely septic ED patients. METHODS: The authors surveyed all emergency physicians (EPs) within a 21-hospital integrated health care delivery system that had recently instituted a modified Rivers protocol for providing early goal-directed therapy (EGDT) to patients with severe sepsis or septic shock, including CVC if indicated. This initiative was accompanied by a structured, but optional, systemwide hands-on training for EPs in real-time ultrasound-guided CVC (US CVC). EPs' responses to questions regarding self-reported experience with CVC in the ED are reported. Data included frequency of CVC (by type) and US CVC training opportunities: both during and after residency and informal ("on-the-job training involving actual ED patients under the oversight of someone more experienced than yourself") and formal ("off-the-job training not involving actual ED patients"). The survey also asked respondents to report their comfort levels with different types of CVC as well as their agreement with possible barriers (philosophical, time-related, equipment-related, and complication-related) to CVC in the ED. Multivariable ordinal logistic regression was used to identify provider characteristics and responses associated with higher yearly CVC volumes. RESULTS: The survey response rate among eligible participants was 365 of 465 (78%). Overall, 154 of 365 (42%) respondents reported performing 11 or more CVCs a year, while 46 of 365 (13%) reported doing two or fewer. Concerning CVC techniques, 271 of 358 (76%) of respondents reported being comfortable with the internal jugular approach with US guidance, compared to 200 of 345 (58%) with the subclavian approach without US. Training rates were reported as 1) in residency, formal 167 of 358 (47%) and informal 189 of 364 (52%); and 2) postresidency, formal 236 of 359 (66%) and informal 260 of 365 (71%). The most commonly self-reported barriers to CVC were procedural time (56%) and complication risk (61%). After multivariate adjustment, the following were significantly associated with greater self-reported CVC use (p < 0.01): 1) informal bedside CVC training after residency, 2) male sex, 3) disagreement with complication-related barrier questions, and 4) self-reported comfort with placing US-guided internal jugular catheters. CONCLUSIONS: In this cross-sectional survey-based study, EPs reported varying experience with CVC in the ED and reported high comfort with the US CVC technique. Postresidency informal training experience, male sex, negative responses to complication-related barrier questions, and comfort with placing US-guided internal jugular catheters were associated with yearly CVC volume. These results suggest that higher rates of CVC in eligible patients might be achieved by informal training programs in US and/or by disseminating existing evidence about the low risk of complications associated with the procedure.

Central venous cutdown in neonates: feasibility as a bedside procedure without general anesthesia.

BACKGROUND/PURPOSE: A silicone central venous catheter (CVC) is usually inserted using a percutaneous technique under general anesthesia. However, there are numerous reports on the postoperative adverse effects of general anesthesia in neonates. The aim of this study is to investigate the feasibility of open surgical cutdown (OSC) for central venous access without general anesthesia. METHODS: The medical records of patients who underwent OSC at bedside under sedation and local anesthesia were reviewed. Chloral hydrate (100mg/kg) was given orally for the induction of moderate to deep sedation 15 minutes before OSC; then the operative field was infiltrated with 1% lidocaine. When adequate sedation was not achieved, a bolus of phenobarbital (20mg/kg) was given intravenously. RESULTS: Thirteen Broviac lines were inserted into 12 patients. At insertion, the median gestational age was 29 weeks, birth weight was 1,140 g and age was 33 days. No patients required invasive ventilator care; 7 patients received nasal non-invasive ventilator care. Neither intubation nor inotropics were required during the intra- or postoperative period and no perioperative surgical complications occurred. The median catheter duration was 19.5 days. CONCLUSION: OSC at bedside for CVC insertion, using adequate sedation and local anesthesia, is a feasible procedure in neonates.

A model of chronic nutrient infusion in the rat.

Chronic exposure to excessive levels of nutrients is postulated to affect the function of several organs and tissues and to contribute to the development of the many complications associated with obesity and the metabolic syndrome, including type 2 diabetes. To study the mechanisms by which excessive levels of glucose and fatty acids affect the pancreatic beta-cell and the secretion of insulin, we have established a chronic nutrient infusion model in the rat. The procedure consists of catheterizing the right jugular vein and left carotid artery under general anesthesia; allowing a 7-day recuperation period; connecting the catheters to the pumps using a swivel and counterweight system that enables the animal to move freely in the cage; and infusing glucose and/or Intralipid (a soybean oil emulsion which generates a mixture of approximately 80% unsaturated/20% saturated fatty acids when infused with heparin) for 72 hr. This model offers several advantages, including the possibility to finely modulate the target levels of circulating glucose and fatty acids; the option to co-infuse pharmacological compounds; and the relatively short time frame as opposed to dietary models. It can be used to examine the mechanisms of nutrient-induced dysfunction in a variety of organs and to test the effectiveness of drugs in this context.