Ultrasound-guided central venous catheterization around the neck: Systematic review and network meta-analysis.

BACKGROUND: Ultrasound-guided central venous catheterization (CVC) has become the standard of care. However, providers use a variety of approaches, encompassing the internal jugular vein (IJV), supraclavicular subclavian vein (SupraSCV), infraclavicular subclavian vein (InfraSCV), proximal axillary vein (ProxiAV), distal axillary vein (DistalAV), and femoral vein. OBJECTIVE: This review aimed to compare the first-pass success rate and arterial puncture rate for different approaches to ultrasound-guided CVC above the diaphragm. METHODS: In May 2023, Embase, MEDLINE, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform were searched for randomized controlled trials (RCTs) comparing the 5 CVC approaches. The Confidence in Network Meta-Analysis tool was used to assess confidence. Thirteen RCTs (4418 participants and 13 comparisons) were included in this review. RESULTS: The SupraSCV approach likely increased the proportion of first-attempt successes compared to the other 4 approaches. The SupraSCV first-attempt success demonstrated risk ratios (RRs) > 1.21 with a lower 95% confidence interval (CI) exceeding 1. Compared to the IJV, the SupraSCV approach likely increased the first-attempt success proportion (RR 1.22; 95% confidence interval [CI] 1.06-1.40, moderate confidence), whereas the DistalAV approach reduced it (RR 0.72; 95% CI 0.59-0.87, high confidence). Artery puncture had little to no difference across all approaches (low to high confidence). CONCLUSION: Considering first-attempt success and mechanical complications, the SupraSCV may emerge as the preferred approach, while DistalAV might be the least preferable approach. Nevertheless, head-to-head studies comparing the approaches with the greatest first attempt success should be undertaken.

Robotic-assisted laparoscopic hysterectomy and vasovagal reflex: A case report.

No reports of vasovagal reflex activity during robotic-assisted laparoscopic hysterectomy (RALH) exist. We present a case of a woman who underwent a RALH for a uterine myoma with uterine adenomyosis. A lack of tactile feedback and a traction force sensor create unique risks of robot-assisted surgery. Anesthesiologists should be aware of these risks.

Catheter-related thrombosis after cardiac surgery in patients with both central venous and pulmonary artery catheters inserted into the right internal jugular vein: a single-center, prospective, observational study.

Central venous catheters (CVCs) and pulmonary artery catheters (PACs) are widely used in intensive care and perioperative management. The detection and prevention of catheter-related thrombosis (CRT) are important because CRT is a complication of catheter use and can cause pulmonary embolism and bloodstream infection. Currently, there is no evidence for CRT in patients using both CVC and PAC. We conducted a single-center, prospective, observational study to identify the incidence, timing, and risk factors for CRT in patients undergoing cardiovascular surgery and using a combination of CVC and PAC through the right internal jugular vein (RIJV). Out of 50 patients, CRT was observed using ultrasonography in 39 patients (78%), and the median time of CRT formation was 1 day (interquartile range: 1-1.5) after catheter insertion. The mean duration of PAC placement was 3 days (interquartile range: 2-5), and the maximum diameter of CRT was 12 mm (interquartile range: 10-15). In short-axis images, CRT occupied more than half of the cross-sectional area of the RIJV in five patients (10%), and CRT completely occluded the RIJV in one patient (2%). Platelet count, duration of PAC placement, and intraoperative bleeding amount were found to be high-risk indicators of CRT. In conclusion, patients who underwent cardiovascular surgery and using both CVC and PAC had a high incidence of CRT. Avoiding unnecessary PAC placement and early removal of catheters in patients at high risk of developing CRT may prevent the development of CRT.

Life-Threatening Complications Related to Delayed Diagnosis of Euglycemic Diabetic Ketoacidosis Associated with Sodium-Glucose Cotransporter-2 Inhibitors: A Report of 2 Cases.

BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are widely used owing to their effective glycemic control and protective effects against heart and kidney failure. Euglycemic diabetic ketoacidosis (eu-DKA) is a complication of treatment with SGLT2is. Eu-DKA often leads to delayed diagnosis and results in life-threatening complications. We report 2 critical cases of SGLT2i-associated eu-DKA. CASE REPORT Case 1 was 52-year-old woman with unstable angina scheduled for elective coronary artery bypass grafting surgery. Preoperatively, she underwent tooth extraction which led to poor food intake because of pain. Three days before surgery, the patient had SGLT2i-associated eu-DKA and myocardial infraction, requiring percutaneous coronary intervention and peripheral venoarterial extracorporeal membrane oxygenation. The patient had taken SGLT2i until the morning of admission to the intensive care unit. Case 2 was a 76-year-old woman experiencing SGLT2i-associated eu-DKA and sinus arrest, necessitating a temporary pacemaker, followed by elective gastrojejunal bypass surgery. The SGLT2i was discontinued the day before surgery. On day 3 following surgery, the patient's metabolic acidosis improved, and sinus arrest resolved. CONCLUSIONS Precipitating factors of eu-DKA (caloric restriction and surgical stress) and delay in diagnosis because of a lack of evidence of hyperglycemia could contribute to the development and worsening of life-threatening complications. This reiterates the importance of reviewing ongoing medications of patients with diabetes and considering eu-DKA as a differential diagnosis for patients with high anion gap metabolic acidosis to ensure early intervention. SGLT2i-associated DKA likely develops perioperatively; therefore, clinicians should pay attention to the discontinuation period of SGLT2i before any surgical intervention.

Videolaryngoscopy for transesophageal echocardiography probe insertion: a systematic review and meta-analysis of randomized controlled trials.

Transesophageal echocardiography (TEE) is a well-established procedure, but serious complications may occur. This systematic review and meta-analysis assessed the utility of videolaryngoscopy-assisted technique in TEE probe insertion. We performed a systematic search in MEDLINE, EMBASE, CENTRAL, and ICTRP. We included RCTs comparing TEE probe insertion techniques assisted with videolaryngoscopy and with any other insertion technique in adult patients. Primary outcome measures were (1) the number of attempts before successful TEE probe insertion, and (2) the risk of any procedural injury to related structures. The secondary outcome measure was time to TEE probe insertion. In total, three studies (n = 266) were included in this systematic review. Overall, a significantly less number of attempts were required with videolaryngoscopy-assisted insertion (mean difference [MD] - 0.60; 95% confidence interval [CI] - 0.73, - 0.46; low quality of evidence). Videolaryngoscopy-assisted technique was also associated with smaller risk of complications (risk ratio [RR] 0.17; 95% CI 0.05, 0.62; low quality of evidence). There was no significant difference in time to probe insertion (MD - 8.57; 95% CI - 26.31, 9.16; very low quality of evidence). The use of videolaryngoscopy for TEE probe insertion is associated with a significant reduction in the number of attempts and complication rate.

High-dose Corticosteroids for Adult Bell's Palsy: Systematic Review and Meta-analysis.

OBJECTIVES: To compare the efficacy and safety of high-dose corticosteroids (initial prednisolone [PSL] of 100 mg or more daily) and standard-dose corticosteroids (initial PSL of 50-60 mg) in patients with Bell's palsy. STUDY DESIGN: A systematic review and meta-analysis. DATA SOURCES: Medline, Embase, Cochrane Central Register of Controlled Trials, Ichushi-Web, Web of Science, and CINAHL, combined with data from ClinicalTrials.gov. STUDY SELECTION: Published and unpublished cohort studies comparing high- and standard-dose corticosteroids in adult patients with Bell's palsy were included. DATA EXTRACTION: Study characteristics (study design, patient's number), patient characteristics (sex, age, disease severity, prescription of antivirals), and outcomes (nonrecovery, any adverse effects). DATA SYNTHESIS: From the 1,974 identified articles, 8 studies were met eligible criteria. Of the included studies, the initial dose in high-dose corticosteroids regimens varied from 120 mg to 200 mg PSL daily. Compared with standard-dose corticosteroids, high-dose corticosteroids were associated with a significantly decreased nonrecovery at 6 months after disease onset (odds ratio 0.42, 95% confidence interval 0.22-0.80; very low quality) in patients with Bell's palsy. No severe adverse effects were observed in patients receiving high- or standard-dose corticosteroids. CONCLUSION: High-dose corticosteroids reduce nonrecovery in patients with Bell's palsy. The dose of high-dose corticosteroids was varied and further prospective study is needed to identify an adequate dose of corticosteroids in these patients.