Needle Migration to the Heart: An Unusual Association of Hemodialysis and Cardiovascular Morbidity.

In this report, we present a unique complication of hemodialysis: the hemodialysis access needle was lost into an arteriovenous fistula. The event went unnoticed for several months. The needle eventually migrated into the right ventricle, requiring an operative retrieval. Loss of the needle was likely unrecognized because of the use of a retracting safety cannula that conceals the needle within a sheath after removal. This case highlights a rare and potentially serious complication of hemodialysis access, demonstrates a possible hazard of retracting safety needles, and reviews the management of foreign bodies that have migrated into the heart.

A prerotational, simulation-based workshop improves the safety of central venous catheter insertion: results of a successful internal medicine house staff training program.

BACKGROUND: The purpose of this study was to evaluate the effectiveness of a simulation-based workshop with ultrasonography instruction in reducing mechanical complications associated with central venous catheter (CVC) insertion. METHODS: A single-center prospective cohort study was conducted in the medical ICU and respiratory step-down unit of an urban teaching hospital. Fifty-six medical house staff members were trained prior to their rotations over a 6-month period. The data on mechanical complication rates after the implementation of the workshop were compared with previous experience when no structured educational program existed. RESULTS: There were 334 procedures in the preeducation period compared to 402 procedures in the posteducation period. The overall complication rate, including placement failure, in the preeducation and posteducation period was 32.9% and 22.9%, respectively (P < .01). Placement failure rate decreased from 22.8% to 16.2% (P = .02), and arterial punctures decreased from 4.2% to 1.5% (P = .03). Ultrasonography usage increased from 3.0% to 61.4% (P < .01). Multivariate analysis demonstrated that interns were more likely to cause overall mechanical complications compared with fellows and attending physicians in the preeducation period (P = .02); however, this trend was not observed in the posteducation period. Catheter site and ultrasonography usage significantly affected the overall complication rate in both periods, and ultrasound-guided femoral CVC was the safest procedure in the posteducation period. CONCLUSIONS: Implementation of a prerotational workshop significantly improved the safety of CVC insertion, especially for CVCs placed by inexperienced operators. We suggest that simulation-based training with ultrasonography instruction should be conducted if house staff members are responsible for CVC placement.

Relationship between proteinuria and venous thromboembolism.

Nephrotic syndrome is known to cause venous thromboembolism (VTE) due to urine loss of antithrombin III and activation of the coagulation system. We hypothesized that the degree of proteinuria may predict the development of VTE. This was a retrospective case-controlled study of in-patients urban academic teaching hospital from April, 2007 to March, 2009 and who had undergone an imaging study for VTE. All radiology reports (N = 1,647) for CT angiography of chest and Doppler sonogram of extremities were reviewed. The following data were collected: race/ethnicity, degree of proteinuria on urinalysis, serum protein and albumin levels, risk factors for VTE and renal function. The study population consisted of 284 patients with VTE and 280 age/sex matched controls. Relative to those who did not have proteinuria, patients who tested positive for protein had a 3.4-fold increased risk of VTE (odds ratio (OR) 3.4, 95% confidence interval [2.4, 5.0]). The association was unchanged when adjusted for other risk factors. Patients with proteinuria may have an increased risk of venous thromboembolism.