Comparison of staples vs suturing for securing central venous catheters.

OBJECTIVE: To determine whether skin staples can be used to secure central venous catheters as effectively as does suturing. METHODS: A prospective, randomized trial of techniques to secure a central venous catheter was performed in a medical school human anatomy laboratory using human cadavers. Central lines were secured to the upper left thorax using either standard suture material (000 silk) or skin staples (5.7 mm x 3.8 mm). Once secured, an upward force was applied to the hub of the catheter perpendicular to the skin. The amount of force needed to break the catheter hub free of the skin was measured in kg. A total of 10 measurements were made for each of 3 methods for securing the catheters (2 sutures, 2 staples, 4 staples). In addition, the site of catheter breakage was recorded. RESULTS: Those catheter hubs secured by 2 sutures required a mean force of 3.1 +/- 0.5 kg to cause breakage, and the break always occurred at the suture. Those hubs secured by 2 staples gave way at 3.0 +/- 0.3 kg (p = NS), while those secured with 4 staples gave way at 4.5 +/- 1.4 kg (p < 0.05). Although 1 hub did break, in all other stapled cases, the break occurred at the staple. CONCLUSIONS: Based on this cadaver model, use of staples appears to be as effective as suturing for securing central venous catheters. Further studies of safety and time for placement are needed.

Decay in quality of closed-chest compressions over time.

STUDY OBJECTIVE: To characterize fatigue-induced deterioration in the adequacy of closed-chest compressions performed over a period of 5 minutes and to determine whether CPR providers can recognize the effects of fatigue on compression adequacy. DESIGN: Prospective evaluation of study subjects performing closed-chest compressions on an electronic mannequin that assesses compression placement and depth. SETTING: Major resuscitation room in rural university hospital emergency department. PARTICIPANTS: Eleven experienced nursing assistants who regularly provide CPR in the ED. RESULTS: Each study participant performed 5 minutes of closed-chest compressions. Compression adequacy (for placement and depth) was assessed with the mannequin and reported on an attached monitor out of view of the study subjects. Subjects were asked to verbally indicate the point during their 5-minute compression period at which they felt too fatigued to provide effective compressions (arbitrarily defined as a minimum of 90% of all compressions being judged correct by the mannequin). We used one-way repeated-measures ANOVA and regression analysis to determine whether compression adequacy diminished over time. ANOVA was also used to determine whether the total compressions performed per minute diminished over time. The percentage of correct chest compressions decreased significantly after 1 minute of compressions (P = .0001). We found 92.9% of compressions performed during minute 1 to be correct. The percentages for minutes 2 through 5 were as follows: 67.1%, 39.2%, 31.2%, and 18.0%. Regression analysis revealed a decrement in compression adequacy of 18.6% per minute after the first minute of compressions. The number of total compressions attempted per minute did not decrease (P = .98). Study subjects did not accurately identify the point during their 5-minute sessions at which their fatigue caused compressions to become impaired. Whereas mean compression adequacy declined below 90% after only 1 minute, the time of indicated fatigue was 253 +/- 40 seconds (mean +/- SD). CONCLUSION: Although compression rate was maintained over time, chest compression quality declined significantly over the study period. Because CPR providers could not recognize their inability to provide proper compressions, cardiac arrest team leaders should carefully monitor compression adequacy during CPR to assure maximally effective care for patients receiving CPR.

Red cabin lights impair air medical crew performance of color-dependent tasks.

INTRODUCTION: Red cabin lighting is often used for nighttime patient transports in helicopters. This study was conducted to determine if red lighting results in impairment of color-dependent tasks. METHODS: An emergency medical services pilot adjusted red lighting in a BO-105 cabin to maximum acceptable intensity. Thirteen emergency room residents were shown positive and negative CO2 detectors and skin-colored and cyan-tinted rubber masks; percentages of correctly identified masks and detectors were noted. Subjects also read drug name and amount from 12 medication labels. Wilcoxon analysis (p = 0.05) was used to compare label reading accuracy between two groups: control (black/white lettering/background) and red (red lettering or background). RESULTS: Percentages of accurately identified masks and detectors in the red light setting were as follows: normal mask 61.5%, cyanotic mask 30.8%, negative and positive CO2 detectors 46.2%. Ability to correctly read medication labeling was significantly (p = 0.003) greater in control (76.9 +/- 10.9%) as compared to red groups (16.3 +/- 13.4%). CONCLUSION: Red cabin lighting appears to impair performance of certain critical tasks requiring color discernment. Consideration of this by medical crews working under red light conditions could reduce risk for patient-care errors.

Tracheal mucociliary transport rate in awake dogs.

To measure tracheal mucociliary transport rate (TMTR) in awake dogs, restrained in dorsal recumbency, 99mtechnetium-labeled macroaggregated albumin was administered by tracheal injection, and the cephalic movement of boluses containing the radiopharmaceutical was detected by a gamma camera positioned lateral to the dog's head and neck. The distance traveled by each bolus was measured, relative to external markers placed a known distance apart. Tracheal mucociliary transport rates were calculated by dividing the measured distance of radiopharmaceutical movement by elapsed time. The technique was efficient and well tolerated. Mean (+/- SD) TMTR was 35.3 +/- 15.9 mm/min. Significant (P = 0.029) difference in TMTR was found between males and females, but significant difference attributable to age of the dog was not detected. This method of measuring TMTR in awake dogs has potential for evaluation of clinical animal patients with suspected tracheal mucociliary abnormalities.

Use of hepatobiliary scintigraphy in the diagnosis of extrahepatic biliary obstruction in dogs and cats: 25 cases (1982-1989).

Twenty-five animals (21 dogs and 4 cats) in which hepatobiliary scintigraphy (HBS) was performed between 1982 and 1989 were included in a retrospective study to determine the utility of HBS for diagnosis of extrahepatic biliary obstruction. Final diagnoses, which were based on liver biopsy results and surgical findings in all animals, were hepatocellular disease alone (n = 17), hepatocellular disease and extrahepatic biliary obstruction (n = 7), and normal liver (n = 1). Hepatobiliary scintigraphy was performed by use of 99mTc-diisopropyl iminodiacetic acid in all cases. All 7 cases of extrahepatic biliary obstruction were confirmed at surgery. In animals with biliary obstruction, HBS failed to demonstrate radiolabel within either the gallbladder or intestine at any time. Using nonvisualization of the intestine by 180 minutes as the scintigraphic criterion for diagnosis of biliary obstruction, sensitivity was 83% and specificity was 94% in this series. Hepatobiliary scintigraphy was concluded to be an accurate indicator of extrahepatic biliary obstruction in this group of animals. High serum bilirubin concentration at the time HBS was performed did not appear to reduce the diagnostic usefulness of the scintigraphic findings.

Lymphoscintigraphy in healthy dogs and dogs with experimentally created thoracic duct abnormalities.

Lymphoscintigraphic evaluation of the thoracic duct (TD) was performed in 10 healthy and 12 dogs with experimentally created TD abnormalities (6 dogs with TD lacerations and 6 dogs with cranial vena ligations). Complete imaging took 4 hours and caused no adverse effects or complications. Lymphoscintigraphy of healthy dogs failed to image the TD; however, background activity in the abdomen and thorax, and radioactivity in the kidneys, bladder, liver, and heart were noticed. Lacerations and transections of the TD were experimentally created in 6 dogs to ascertain whether TD rupture could be detected with lymphoscintigraphy. Lymphoscintigraphy was performed within 48 hours of creating the TD defect. There was no significant difference in the scintigraphic pattern of healthy dogs and those with experimentally created TD defects. Ligation of the cranial vena cava was performed in 6 dogs; 3 dogs developed chylothorax. In those 3 dogs, diffuse radioactivity was imaged in the thorax and was compatible with thoracic lymphangiectasia. In one of these dogs, linear activity consistent with the TD and localized regions of radioactivity cranial to the heart (compatible with the mediastinal lymph nodes) were noticed. Lymphoscintigraphic findings in these dogs correlated with lymphangiographic findings.

Multicentric osseous lymphoma with spinal extradural involvement in a dog.

Multicentric osseous lymphoma involving the ribs and multiple vertebrae was observed in a 7-year-old Siberian Husky. Extradural spinal cord compression was treated by surgical decompressive hemilaminectomy of L1-2 without noticeable improvement of signs neurologic dysfunction. However, palliation of signs of pain was noticed after irradiation in conjunction with chemotherapy and surgical decompression.

Comparison of four methods of estimating glomerular filtration rate in cats.

Four methods of evaluating renal function were performed in 6 cats anesthetized with halothane in oxygen. Glomerular filtration rate (GFR) was measured simultaneously in each cat by exogenous creatinine clearance (ECC), bolus inulin clearance, and 99mTc(Sn)-diethylene-triaminepentaacetic acid (DTPA) clearance determined by 2 different methods. In the first DTPA clearance method (DTPA-1), we measured radioactivity in serial blood specimens to construct plasma disappearance curves for calculation of GFR. In the second DTPA clearance method (DTPA-2), we used serial external head counts of radioactivity and a single blood specimen to construct plasma disappearance curves for calculation of GFR. Bolus inulin clearance was calculated from plasma disappearance curves using a 1-compartment open pharmacokinetic model (IN-1) and a 2-compartment open pharmacokinetic model (IN-2). Glomerular filtration rates were measured over 3 hours, for creatinine and DTPA methods, and over 4 hours for the inulin methods. The GFR obtained with the reference method (ECC) was 2.56 +/- 0.61 ml/min/kg of body weight (mean +/- SD). Values for GFR determined by ECC and DTPA-1 were significantly correlated (r = 0.852; P less than or equal to 0.05). Correlation between ECC and DTPA 2 was not as good (r = 0.783; P less than or equal to 0.10), but the 2 DTPA methods significantly correlated with one another (r = 0.897; P less than or equal to 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of beta-tricalcium phosphate in surgically created subchondral bone defects in male horses.

beta-Tricalcium phosphate (TCP) was evaluated as a synthetic bone grafting material in horses. Sixteen horses were randomly assigned to 4 groups of 4 horses. In each horse, an 11-mm by 10-mm circular defect with a smooth margin was created surgically in the weight-bearing surface of both third metacarpal bones (McIII) and the left third metatarsal bone. The defect in the left McIII was filled with TCP, the defect in the right McIII was filled with a mixture of 50% autogenous cancellous bone (ACB) and 50% TCP, and the defect in the left third metatarsal bone was not filled to serve as a control. Nuclear imaging and radiographic evaluation of surgical sites were performed at postsurgical week (PSW) 4 and 13 in group-I horses and at PSW 26, 39, and 52 in groups-II, -III, and -IV horses, respectively. Horses in groups I, II, III, and IV were euthanatized at PSW 13, 26, 39, and 52, respectively, and specimens were harvested for histologic evaluation. Results were compared among treatment methods, as well as among time intervals. The greatest activity at defect sites was seen in group-I horses at PSW 4. Activity counts in limbs of group-I horses at PSW 13 and counts in limbs of group-II horses at PSW 26 were not significantly (P less than or equal to 0.05) different. Activity counts in groups-III and -IV horses at PSW 39 and 52, respectively, were less than those in groups I and II. However, there was no significant difference in activity counts between limbs implanted with TCP or ACB:TCP.(ABSTRACT TRUNCATED AT 250 WORDS)

Radionuclide, radiographic, and histomorphometric evaluation of healing of surgically created subchondral defects in equine bone.

In the present study, radionuclide scintigraphy and radiography were used to evaluate the rate and degree of healing that occurred in surgically created subchondral bone defects in horses. Following radionuclide scintigraphy and radiography the horses were killed, and histomorphometric analysis was performed on the defect sites. The histomorphometric results were compared to the radionuclide scintigraphic and radiographic results to determine which noninvasive technique provided the most accurate information concerning healing of the bone defects. It was concluded that radionuclide scintigraphy and radiographic evaluation seemed equally well suited for use in serial evaluation of healing of surgically created bone defects. However, it was felt that the most accurate assessment of healing of the bone defects and effects in the adjacent bone could be provided by combining the two methods of evaluation.

CT in the management of periappendiceal abscess.

Abdominal CT was the primary diagnostic method used to evaluate 40 patients with suspected periappendiceal abscess. Its subsequent impact on patient management was then analyzed for several categories of clinical presentation, including patients with and without a palpable right-lower-quadrant mass and postoperative patients. CT was reliable in distinguishing periappendiceal abscesses from phlegmons; 17 of 18 patients with phlegmons responded promptly to antibiotic therapy alone without need for surgery. Patients with larger, poorly localized abscesses underwent early surgical drainage. CT was successful in guiding percutaneous catheter drainage (nine patients) or aspiration (one patient) of well-localized periappendiceal abscesses in 10 of 11 patients. One attempted catheter drainage guided by sonography was technically unsuccessful. In patients without a palpable right-lower-quadrant mass, CT was helpful in establishing the diagnosis of periappendiceal inflammation. However, there were three false-positive diagnoses in patients with pericecal fluid collections including a ruptured cecal lymphoma, a ruptured cecal diverticulum, and a ruptured corpus luteum cyst. A diagnostic approach with CT is presented in patients with suspected periappendiceal abscess.

Evaluation of renal function in cats, using quantitative urinalysis.

Two consecutive 24-hour quantitative urinalyses were performed on each of 12 healthy adult cats to evaluate the technique and obtain reference values for measurements of urinary excretion of several substances. Endogenous creatinine clearance (2.31 +/- 0.47 ml/min/kg) and urinary protein excretion (17.43 +/- 9.05 mg/kg/day) were determined. Additionally, clearances and ratios to creatinine clearances were calculated for phosphate, sodium, potassium, and chloride. The endogenous creatinine clearance value was compared with another estimate of glomerular filtration rate that was based on 99mTc(Sn) diethylene-triaminepentaacetic acid clearance (2.52 +/- 0.58 ml/min/kg). Evaluation of feline renal function, using 24-hour quantitative urinalysis techniques, has potential for clinical application, but has several important limitations as well.

Obstruction of the superior vena cava or subclavian veins: sonographic diagnosis.

The normal subclavian vein shows a respiratory rhythmicity on sonograms and responds to a sudden sniff maneuver by collapsing in a rapid, transient manner secondary to the sudden decrease in intrathoracic pressure. Of 11 patients studied using ultrasound (US) for possible superior vena cava (SVC) obstruction, five patients with proved SVC obstruction had no response of the enlarged subclavian veins to respiratory maneuvers. One patient with a partial obstruction had a minimal response on one side. Two patients with isolated subclavian vein obstructions had no response on the affected side and a normal response on the contralateral side. Three patients proved not to have SVC obstruction had normal responses. Sonography of the subclavian veins may be an effective, indirect screening technique for the presence of SVC obstruction and can also be used to evaluate the patency of the subclavian vein, although the sensitivity and specificity of the method remain to be determined from a larger, prospective study.

Sonographic evaluation of the normal response of subclavian veins to respiratory maneuvers.

Sonography of the subclavian veins is a new noninvasive, simple technique to evaluate the subclavian veins. The physiologic changes of the subclavian veins consistently respond in a predictable manner to simple respiratory maneuvers. The subclavian veins of 11 normal patients (22 veins) whose ages ranged from 18 to 60 years were studied. The most significant change in subclavian vein anteroposterior diameter during respiratory maneuvers (Valsalva/expiration/inspiration) occurred with inspiration (P less than .005), particularly during a sniff, with a mean decrease in diameter of 61%. This baseline evaluation establishes normal sonographic criteria of the subclavian veins. We suggest that real-time ultrasound using a high resolution transducer offers a rapid, reproducible, objective method of evaluating the subclavian vein directly.

A tandem guide for renal biopsy.

Percutaneous renal biopsy with direct ultrasound guidance can minimize complications of the biopsy procedure. Presently, many laboratories use ultrasound to localize the kidney, and to calculate the appropriate depth and angle for biopsy needle placement. The actual biopsy, however, is performed blindly. A modification of this technique is presented wherein a 22-gauge guide needle is directed into the kidney using direct ultrasound visualization. This needle serves as a tandem guide for the biopsy needle. The technique reduces the number of unsuccessful needle passes, and minimizes the time required for the procedure, patient discomfort, and potential morbidity.

Lymphatic clearance of radioactive sulfur colloid.

Lymphatic clearance of radioactive sulfur colloid is measured in the hind limb of five mongrel dogs. A solid state Si(Li) detector is placed onto the skin to continuously record activity over the site of subcutaneous injection. Decrease in activity follows an exponential decay which is modeled as a dual decay occurring from both the radioactive decay of the tracer and the lymph clearance of the tagged sulfur colloid. The calculated decay constants for lymph clearance flow per tissue volume result in a mean value of 0.233 +/- 0.077 ml/hr/ml which is consistent with results of other investigators. Adjacent lymph nodes are monitored with a scintillation detector to show that the colloid is absorbed by the lymph vessels. The carotid artery and liver are similarly monitored to show that there is little or no capillary absorption of the tagged colloid.

Clinical pulmonary perfusion imaging in the dog.

Scintigraphic pulmonary perfusion imaging in the dog has been described for the clinically normal animal. The usefulness of this technique in the patient with pulmonary dysfunction was assessed by review of 76 consecutive clinical cases completed in a 6-month period. This review indicated that 3 basic patterns of perfusion defects are commonly seen in the dog. These were associated with (1) diffuse parenchymal metastatic disease, (2) mediastinal metastatic disease, and (3) heartworm disease. The technique has proved reliable as an aid in the staging of neoplastic disease and of some potential value in heartworm disease and is now performed on a routine basis at this institution for purposes of clinical diagnosis.