Incidence of posterior vessel wall puncture during ultrasound-guided vessel cannulation in a simulated model.

OBJECTIVES: The incidence of posterior vessel wall puncture (PVWP) during central line placement with possible subsequent injury to structures lying behind the vein is unknown. At times the internal jugular vein lies immediately anterior to the carotid artery rather than lateral to it, leading to potential arterial puncture should the needle pass through the vein completely. The objective of this study is to evaluate the incidence of PVWP during simulated ultrasound (US)-guided vessel cannulation. METHODS: Enrolled subjects were emergency medicine resident and attending physicians. Subjects performed US-guided venous access on simulated blood vessels within gelatin-based US phantoms. While blinded to the purpose of the study, each subject performed successful cannulation of the vessel on separate phantoms, with wire placement confirmed by expert review of a follow-up US. Each phantom was subsequently deconstructed to manually inspect for PVWP. RESULTS: Thirty-five subjects with a range of experience in the technique participated, each performing both transverse and long-axis approaches for a total of 70 cannulations. The overall incidence of PVWP was 34% (95% confidence interval [CI] = 22.9% to 45.1%). CONCLUSIONS: This study found a high incidence of inadvertent PVWP during simulated US-guided vessel cannulation in this model.

Patients with detectable cocaethylene are more likely to require intensive care unit admission after trauma.

Cocaethylene (CE) is a toxic metabolite that is formed after simultaneous consumption of cocaine and ethanol. This potent stimulant is more toxic than cocaine and has a longer half-life. The deleterious hemodynamic and cardiovascular effects of CE have been proven in animal models. The aim of this study is to assess the impact of CE on clinical outcomes after trauma. We prospectively enrolled adult (≥13 years) trauma patients requiring admission. Predictor variables were age, sex, mechanism of injury, Injury Severity Score, base deficit, and toxicology groups (ethanol alone, cocaine alone, CE, and none). The outcomes examined were mortality, intensive care unit (ICU) admission, and length of hospital stay (LOS). We used nonparametric tests to compare continuous variables and χ² test to compare categorical data. We constructed a logistic regression to identify variables that could predict mortality and ICU admission. We enrolled 417 patients (74% male; 70% blunt injury; median age, 40 [range, 13-95]; overall mortality, 2.2%). Urine toxicology and serum ethanol level screens classified patients into the following groups: 13.4% ethanol only, 4.1% cocaine only, 8.9% CE, and 46% none. Mortality and LOS were not statistically different among the groups. In logistic regression analysis, none of the variables were statistically significant in predicting mortality. However, the presence of CE significantly increased the likelihood of ICU admission (odds ratio, 5.9; 95% confidence interval, 1.6-22). The presence of detectable CE in the urine does not increase the mortality or LOS in trauma patients requiring admission but does increase the likelihood of ICU admission.