Successful Removal and Replacement of a Stuck Hemodialysis Catheter via Thoracotomy: Report of Two Cases and Literature Review.

Introduction: Stuck tunneled central venous catheters (CVCs) have been increasingly reported. In rare cases, the impossibility of extracting the CVC from the central vein after regular traction is the result of rigid adhesions to the surrounding fibrin sheath. Forced traction during catheter removal can cause serious complications, including cardiac tamponade, hemothorax, and hemorrhagic shock. Knowledge and experience on how to properly manage the stuck catheter are still limited. Case Presentation: Here, we present two cases that highlight the successful removal of the stuck tunneled CVC via thoracotomy through the close collaboration of multidisciplinary specialists in the best possible way. Both patients underwent an unsuccessful attempt at thrombolytic therapy with urokinase, catheter traction under the guidance of digital subtraction angiography and intraluminal balloon dilation. And we reviewed the literature on stuck catheters in the hope of providing knowledge and effective approaches to attempted removal of stuck catheters. Conclusion: There is no standardized procedure for dealing with stuck catheters. Intraluminal percutaneous transluminal angioplasty should be considered as the first-line treatment, while open surgery represents a second option only in the event of failure. Care must be taken that forced extubation can cause patients life-threatening.

Point of care ultrasonography as the new "Laennec Sthetoscope".

Point of care ultrasonography (POCUS) has evolved to become the fifth pillar of the conventional physical examination, and use of POCUS protocols have significantly decreased procedure complications and time to diagnose. However, lack of experience in POCUS by preceptors in medical schools and nephrology residency programs are significant barriers to implement a broader use. In rural and low-income areas POCUS may have a transformative effect on health care management.

The use of procedural kits may reduce unscheduled central line dressing changes: A matched pre-post intervention study.

Background: Unscheduled dressing changes for central venous lines (CVLs) have been shown to increase the risk of bloodstream infections. Objective: The objective of this study is to determine if the use of an innovative dressing change kit reduces the rate of unscheduled dressing changes. Methods: This pre-post interventional study took place at a large, academic, tertiary care center in metro Detroit, Michigan, the United States. We assessed the impact of the interventional dressing change procedure kit on the rate of unscheduled dressing changes for adult patients who underwent placement of a CVL inclusive of a central catheter, peripherally inserted central catheter, or hemodialysis catheter. Data was collected for the pre-intervention cohort through electronic health records (EHRs), while data for the post-intervention cohort were collected by direct observation by trained research staff in combination with EHR data. The primary outcome was the rate of unscheduled dressing changes. Secondary outcomes included rate of unscheduled dressing changes based on admission floor type, etiology of unscheduled dressing changes, and central line-associated bloodstream infections (CLABSIs). Results: The study included a convenience sample of 1548 CVLs placed between May 2018 and June 2022 with a matched analysis including 488 catheters in each of the pre- and post-intervention groups. The results showed that the unadjusted rate of unscheduled dressing evaluations was significantly reduced from the pre-intervention group (0.21 per day) to the post-intervention group (0.13 per day) (p < .001). The adjusted rate ratio demonstrated the same trend at 1.00 pre- and 0.60 post-intervention (p < .001). Stratifying the analysis based on the highest level of care showed that the intervention was effective in reducing the unadjusted rate of unscheduled dressing evaluations for both the advanced and regular medical floor subgroups pre- to post-intervention; the advanced subgroup had an reduction from 0.22 to 0.15 per day (p = .001), while the regular medical floor subgroup had a reduction from 0.21 to 0.09 per day (p < .001). CLABSIs were similar in both groups (0.6% vs 0.8%; p = 1.00) in pre- and post-intervention groups, respectively. Discussion: Procedural kits for central line dressing changes are effective in reducing unscheduled dressing changes and may have a role in reducing CLABSI. Further studies assessing the impact of dressing change kits on cost, procedural compliance, and the precise impact on CLABSI are needed.

On the way to the azygos vein: a road of return rather than ruined.

BACKGROUND: The malposition of central venous catheters (CVCs) may lead to vascular damage, perforation, and even mediastinal injury. The malposition of CVC from the right subclavian vein into the azygos vein is extremely rare. Here, we report a patient with CVC malposition into the azygos vein via the right subclavian vein. We conduct a comprehensive review of the anatomical structure of the azygos vein and the manifestations associated with azygos vein malposition. Additionally, we explore the resolution of repositioning the catheter into the superior vena cava by carefully withdrawing a specific length of the catheter. CASE PRESENTATION: A 79-year-old female presented to our department with symptoms of complete intestinal obstruction. A double-lumen CVC was inserted via the right subclavian vein to facilitate total parenteral nutrition. Due to the slow onset of sedative medications during surgery, the anesthetist erroneously believed that the CVC had penetrated the superior vena cava, leading to the premature removal of the CVC. Postoperative contrast-enhanced computed tomography of the chest confirmed that the central venous catheter had not penetrated the superior vena cava but malpositioned into the azygos vein. The patient was discharged 15 days after surgery without any complications. CONCLUSIONS: CVC malposition into the azygos vein is extremely rare. Clinical practitioners should be vigilant regarding this form of catheter misplacement. Ensuring the accurate positioning of the CVC before each infusion is crucial. Utilizing chest X-rays in both frontal and lateral views, as well as chest computed tomography, can aid in confirming the presence of catheter misplacement.

Vascular access route venture of the chronic hemodialysis patient: A prospective cohort study.

OBJECTIVES: This study aimed to collect evidence to improve the arteriovenous fistula practice by investigating vascular access routes and by identifying the factors influencing the preferred types of vascular access routes for the first-time hemodialysis in our center. METHODS: We performed an epidemiological, prospective, cohort study. The study included 308 patients, who underwent hemodialysis for the first time between March 2023 and August 2023 in our hemodialysis center. We evaluated biochemical parameters, preferred vascular access routes for the first-time hemodialysis, planned/emergency hemodialysis status, the qualifications of the healthcare provider, who inserted the central venous catheter, if applicable, the presence of hypervolemia, anticoagulant use, nephrology follow-up findings, and in-hospital mortality in all patients and in those, who continued with chronic hemodialysis. RESULTS: The number of patients, who continued with chronic hemodialysis, was 167 (54.2%) and a temporary internal jugular central venous catheter was the most commonly preferred vascular access route for the first-time hemodialysis (47.3%). A central venous catheter was most commonly inserted by a nephrologist (53.7%) in chronic hemodialysis patients. Of the patients continuing with chronic hemodialysis, 45.5% were followed up in the nephrology outpatient clinic, 9.6% initiated hemodialysis on a planned basis, and 8.4% initiated hemodialysis with an arteriovenous fistula. A temporary internal jugular central venous catheter was commonly preferred when patients were followed up in the nephrology clinic and when the insertion was performed by a nephrologist; a transient femoral central venous catheter was commonly preferred in case of hypervolemia (p < .001, p < .001, and p = .028, respectively). Age, gender, etiology, anticoagulant use, or biochemical test results did not act on the selection of the access site for the insertion of central venous catheter at the time of the first hemodialysis treatment. The access site for central venous catheter was not associated with in-hospital mortality (p = .644). In the overall patient group, the in-hospital mortality was significantly low in patients followed up in the nephrology clinic (p = .014). CONCLUSION: The use of pre-emptive arteriovenous fistula for the first hemodialysis treatment occurs much less commonly than expected. Hemodialysis initiation rates with pre-emptive arteriovenous fistula lag behind nephrology outpatient follow-up rates.

An analysis of central venous catheter-related bloodstream infections in patients treated in a Swedish Covid-19 intensive care unit.

Background: Catheter-related bloodstream infection is a well-known, severe complication of central venous catheter insertion. Studies that have evaluated the coronavirus disease 2019 pandemic's influence on the incidence of catheter-related bloodstream infection in intensive care units are limited. Therefore, we conducted a retrospective study on catheter-related bloodstream infection in coronavirus disease 2019 intensive care unit with previously documented low incidence rates to evaluate the pandemic's impact. Objectives: To evaluate the impact of the coronavirus disease 2019 pandemic on catheter-related bloodstream infection incidence in the intensive care unit. Methods: All central venous catheter-inserted patients aged ⩾18 years admitted to the intensive care unit with coronavirus disease 2019 pneumonia were included. The primary outcome was the incidence of catheter-related bloodstream infection, and the secondary outcome was the detection of catheter-related bloodstream infection-causative microorganisms. Results: During the pandemic's first year, 124 patients were admitted, and 203 central venous catheters were inserted. Two patients developed catheter-related bloodstream infection. The incidence of catheter-related bloodstream infection was 0.79/1000 catheter days. The microorganisms responsible for catheter-related bloodstream infection were Staphylococcus epidermidis and Escherichia coli. Conclusion: This study revealed a low incidence of catheter-related bloodstream infection in the coronavirus disease 2019-intensive care unit, thus suggesting that coronavirus disease 2019 is not a risk factor for catheter-related bloodstream infection and indicating the high resilience of well-established routines aimed at catheter-related bloodstream infection prevention.

Right subclavian artery injury during catheter insertion into the right internal jugular vein treated with endovascular stent graft placement after balloon occlusion test: A case report.

Subclavian artery injuries during internal jugular vein puncture when attempting central venous catheter insertion are rare. A 60-year-old man undergoing treatment for neuromyelitis optica with paralysis and sensory loss developed a complication during catheter placement into his right internal jugular vein for plasmapheresis. His previous physician felt resistance and discontinued the procedure. The patient later developed mild dyspnea and dysphagia. Computed tomography scans indicated thrombus formation and tracheal deviation. Contrast-enhanced computed tomography scans showed right subclavian artery injury with extravasation and a large pseudoaneurysm. Following transferal to our hospital, he was stable and asymptomatic; however, contrast-enhanced computed tomography scans showed a pseudoaneurysm located proximal to the right subclavian artery. Considering challenges with compression hemostasis and the invasiveness of open surgery, endovascular treatment was selected using a VIABAHN stent graft. A balloon occlusion test of the right vertebral artery was performed to assess stroke risk. Prophylactic embolization of the right vertebral artery, internal thoracic artery, and thyrocervical trunk were performed to prevent a type 2 endoleak. On hospital day 5, our patient showed no postoperative complications and was transferred to the referring hospital. Follow-up imaging showed the graft was intact with no pseudoaneurysm, confirming successful treatment. Endovascular treatment with a stent graft is highly effective for peripheral artery injuries. Using a balloon occlusion test to assess collateral blood flow and stroke risk is essential pretreatment, especially when a graft might occlude the vertebral artery. Balloon occlusion tests are recommended when planning treatment for iatrogenic and other types of subclavian artery injuries.

Uncommon Culprit, Familiar Foe: A Case of Septic Thrombophlebitis of the Internal Jugular Vein Triggered by Klebsiella Bacteremia.

Septic thrombophlebitis of the internal jugular vein is characterized as Lemierre syndrome. Patients typically present with sore throat and fever and may present with a tender neck mass due to thrombophlebitis of the internal jugular vein. We present the case of a 57-year-old male with neck pain, fever, chills, and headaches who was diagnosed with internal jugular vein septic thrombophlebitis associated with catheter-related introduction of bacteria.

Results of a long-term, prospective study on complications of central venous catheter in pediatric patients with hematologic-oncologic diseases.

BACKGROUND: Central venous catheter (CVC)-related complications remain a significant cause of morbidity in pediatric hematology-oncology. We prospectively surveyed the incidence of CVC-related complications in children with hematologic-oncologic diseases. PROCEDURE: Five-hundred-eighty-one CVCs were inserted in 421 patients from January 2010 to June 2022 (153,731 CVC days observation; follow-up data up to December 31, 2022). RESULTS: Overall, 671 complications were recorded (4.365/1000 CVC days): 49.7% malfunctions (1.88/1000 CVC days, 4.8% of CVC early removals), 23.9% bacteremia (0.90/1000, 15.1%), 19.6% mechanical complications (0.74/1000, 70.2%), 20.1% localized infections (0.76/1000, 17.1%), 0.5% thrombosis (0.02/1000, 33.3%). At multivariate analysis, risk factors for malfunction were Broviac-Hickman type of CVC (hazard ratio [HR] 2.5) or Port-a-cath (HR 3.4) or Proline (HR 4.3), p < .0001; for bacteremia double-lumen CVC (HR 3.2, p < .0001); for mechanical complications age at CVC insertion under median (HR 4.5, p < .0001) and Broviac-Hickman (HR 1.6) or Proline (HR 2.7), p = .01; finally for localized infections Broviac-Hickman (HR 2.9) or Proline (HR 4.4), p = .0001. The 2-year cumulative incidence of premature removal was 23.5%, and risk factors were age at CVC insertion under median (HR 2.4, p < .0001), Broviac-Hickman (HR 2.3) or Proline (HR 4.2), p < .0001. CONCLUSIONS: Premature removal occurs in approximately 20%-25% of long-term CVCs. A surveillance program has a fundamental role in identifying the risk factors for CVC complications and the areas of intervention to improve CVC management.

Incidence and clinical progression of asymptomatic peripherally inserted central catheter-related thrombosis in solid neoplasm patients: ultrasound insights from a prospective cohort study.

Background: Managing central venous catheters in patients with neoplasms is challenging, and peripherally inserted central catheter PORT (PICC-PORT) has emerged as a promising option for safety and efficacy. However, understanding the clinical progression of catheter-related thrombosis (CRT) in cancer patients with central venous catheters remains limited, especially in certain neoplasm types associated with a higher risk of venous thrombosis. Objectives: This study aims to assess the effectiveness of ultrasound-guided management in detecting and treating asymptomatic CRT in cancer patients with PICC. Methods: In this prospective cohort study of 120 patients with solid neoplasms receiving chemotherapy, we investigated the incidence of isolated upper-extremity superficial vein thrombosis, upper-extremity deep vein thrombosis, and fibrin sheath formation through ultrasound follow-up at 30 and 90 days after catheter insertion. We analyzed risk factors associated with CRT and compared incidence rates between PICC-PORT and traditional PICC. Results: Among the cohort, 69 patients (57.5%) had high-risk thromboembolic neoplasm, and 31 cases (25.8%) of CRT were observed, mostly within 30 days, with only 7 cases (22.6%) showing symptoms. Traditional PICC use (odds ratio, 5.86; 95% CI, 1.14-30) and high-risk thromboembolic neoplasm (odds ratio, 4.46; 95% CI, 1.26-15.81) were identified as independent risk factors for CRT. Conclusion: The majority of CRT present asymptomatically within the first 30 days of venous catheter insertion in patients with solid neoplasms. Ultrasound follow-up is valuable for detecting asymptomatic CRT. The risk of CRT was lower with PICC-PORT than with PICC. Additionally, the risk of CRT was found to be higher in patients with high-risk thromboembolic neoplasms. It is crucial for larger studies to confirm the utility of treating asymptomatic thromboses and isolated superficial thrombosis.

Complications after peripherally inserted central catheter versus central venous catheter implantation in intensive care unit: propensity score analysis using a nationwide database.

BACKGROUND: It remains unclear whether peripherally inserted central catheters (PICCs) are superior to central venous catheters (CVCs); therefore, we compared post-implantation complications between CVC and PICC groups. RESEARCH DESIGN AND METHODS: Patients who received CVCs or PICCs between April 2010 and March 2018 were identified from the Diagnosis Procedure Combination database, a national inpatient database in Japan. The outcomes of interest included catheter infection, pulmonary embolism, deep vein thrombosis, and phlebitis. Propensity score overlap weighting was used to balance patient backgrounds. Outcomes were compared using logistic regression analyses. RESULTS: We identified 164,185 eligible patients, including 161,605 (98.4%) and 2,580 (1.6%) in the CVC and PICC groups, respectively. The PICC group was more likely to have overall complications (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.32-2.19), pulmonary embolism (OR, 2.32; 95% CI, 1.38-3.89), deep vein thrombosis (OR, 1.86; 95% CI, 1.16-2.99), and phlebitis (OR, 1.72; 95% CI, 1.27-2.32) than the CVC group. There was no significant intergroup difference in catheter infection (OR, 1.09; 95% CI, 0.39-3.04). CONCLUSIONS: Patients with PICCs had a significantly greater incidence of complications than did those with CVCs. Further research is necessary to explore the factors contributing to these complications.

Evaluation of Central Venous Catheter for Dialysis Associated with Bloodstream Infections.

Objective: Hemodialysis (HD) catheter-related bloodstream infections (CRBSIs) are a major complication of long-/short-term catheter. Material and Methods: Patients with HD CRBSIs were identified, and their blood was taken and sent to clinical pathology for culture and sensitivity testing. The inclusion criteria were adults with end-stage renal disease who required urgent HD access in the presence of a central venous catheter (CVC) infection. Results: The most common isolates among the patients with CRBSIs were gram-positive microorganisms (57.5%) and gram-negative organisms (42.5%). Overall, in our entire study, Staphylococcus aureus was the most common pathogen isolated, accounting for 30%, followed by Pseudomonas aeruginosa (20%), coagulase-negative staphylococci (CoNS) (12.5%), Klebsiella spp. and Acinetobacter (10%), Staphylococcus epidermidis (7.5%), and methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, Staphylococcus hominis, and Enterococcus faecalis (2.5%). The commonest bacterial in femoral was S. aureus, and for subclavian was Pseudomonas aeruginosa. All S. aureus were sensitive to aminoglycosides and quinolones. P. aeruginosa was sensitive to the third generation of cephalosporins, especially cefoperazone and carbapenem. Conclusion: Nontunneled CVCs used for more than 2 weeks could increase the risk of CRBSIs. Procalcitonin and erythrocyte sedimentation rate could predict the CRBSIs in this study. This study also revealed that the gram-positive bacteria were primadonna in dialysis of CRBSIs, and most of them were sensitive to aminoglycosides.

Survival, cumulative hospital days and infectious complications in urgent-start PD compared with urgent-start HD.

BACKGROUND: Urgent-start peritoneal dialysis (PD) carries a similar efficacy and safety profile compared to urgent-start haemodialysis (HD) but is only sparsely applied due to resource issues and concerns of complication risks. Furthermore, few data exist on adverse outcomes associated with central venous catheter (CVC) insertions in urgent-start HD patients. Thus, we sought to compare patient and dialysis-related outcomes in patients undergoing urgent-start PD or HD. METHODS: All patients initiating urgent-start PD in a tertiary research hospital in 2005-2018 were included in this retrospective, single-centre, comparative study and matched with urgent-start HD patients of similar age and chronic kidney disease aetiology. All urgent-start PDs were initiated within 72 h after catheter insertion, and urgent-start HDs were performed via a CVC. All analyses were performed at 3 months and at 1 year of follow-up, respectively. RESULTS: Thirty-three patients who commenced urgent-start PD and 58 matched urgent-start HD control patients were included. Altogether, 26 patients (29%; PD: 36%, HD 24%) died within the 1-year follow-up, and patient survival was similar at 3 months (hazard ratio (HR): 1.15, 95% confidence interval (CI): 0.35-3.81, p = 0.82) and at 1 year of follow-up (HR: 0.64, 95% CI: 0.30-1.39, p = 0.26) between the study groups. There were no differences in the total kidney replacement therapy (KRT)-related infection rate (p = 0.66) or cumulative first-year hospital care days (p = 0.43) between the treatment groups. Altogether, 139 CVCs were inserted during the 1-year follow-up. The number of CVCs per patient was associated with the emergence of blood culture-positive bacteraemia and increased cumulative first-year hospital care days. CONCLUSIONS: Patient survival, cumulative first-year hospital care days and total KRT-related infection rate at 3 months and 1-year follow-up are similar between urgent-start PD and urgent-start HD patients. Furthermore, CVC insertion rate is associated with incident blood culture-positive bacteraemia and increased cumulative first-year hospital care days.

Effects of 1-week inpatient multidisciplinary care for chronic kidney disease prior to outpatient collaborative care.

BACKGROUND: Multidisciplinary care for Chronic Kidney Disease (CKD) has been reported to be effective in preventing deterioration of renal function and avoiding hemodialysis induction using a central venous catheter. METHODS: We included 171 patients who received dialysis at our department between October 2014 and June 2017. Patients were divided into two groups: an inpatient group who received inpatient multidisciplinary care for CKD (educational hospitalization) prior to outpatient collaborative care from their family physician and nephrologist, and a non-inpatient group who did not receive such care. We compared factors related to dialysis induction. RESULTS: There was no significant difference in eGFR between the groups at the start of observation. The mean time from the start of observation to dialysis induction (inpatient group vs. non-inpatient group; 40.8 ± 2.8 vs. 23.9 ± 3.0 months, respectively; P < 0.001) and the rate of hemodialysis induction using a central venous catheter (22.5 vs. 47.1%, respectively; P = 0.002) were significantly different between the groups. Survival analysis showed that the time to dialysis induction was significantly longer in the inpatient group (P = 0.0001). Multivariate analysis revealed that educational hospitalization (odds ratio = 0.30 [95% CI 0.13, 0.67]) was significantly associated with hemodialysis induction using a central venous catheter. CONCLUSION: Educational hospitalization prior to outpatient collaborative care is beneficial for preventing hemodialysis induction using a central venous catheter and postponing dialysis induction.

Diseño y validación de un manual psicoeducativo sobre la colocación de catéter puerto en mujeres con cáncer de mama / Design and validation of a psychoeducational manual on port catheter placement in women with breast cancer

Introducción: Los abordajes educativos son intervenciones recomendadas para atender las necesidades informativas y emocionales de los pacientes con cáncer de mama. Entre ellos se encuentran los materiales psicoeducativos, que idealmente deben de estar desarrollados con base en la evidencia, para favorecer la alfabetización en salud; sin embargo, esto es poco común. Objetivo: Diseñar y validar el contenido de un manual psicoeducativo sobre la colocación del catéter puerto en mujeres con cáncer de mama, así como analizar su nivel de legibilidad. Método: se llevó a cabo una investigación prospectiva y transversal-descriptiva, a través de un diseño de tipo no experimental. Para la evaluación del manual, se contó con la participación de 9 jueces expertos en psicooncología, terapia intravenosa y medicina. Se analizó la validez de contenido con el índice de Osterlind y la dificultad de lectura con el índice INFLESZ. Resultados: El manual obtuvo una excelente evaluación de su contenido con un índice de Osterlind de 0,88 y en el análisis de dificultad de lectura obtuvo una puntuación de 67,3, evidencia de un material muy fácil de leer. Conclusiones: Los hallazgos muestran que el manual desarrollado es de calidad, de fácil acceso y comprensión para los pacientes que se someterán a la colocación de un catéter puerto. Asimismo, se ofrece evidencia de la importancia de construir materiales educativos basados en la investigación y en indicadores estadísticos.(AU)

Introduction: Educational approaches are recommended interventions to address the informational and emotional needs of patients with breast cancer. Among them are psychoeducational materials, which ideally should be evidence-based developed, to promote health literacy; however, this is rare. Objective: Design and validate the content of a psychoeducational manual on central venous catheters in women with breast cancer, as well as analyze its level of readability. Method: a prospective and transversal-descriptive research was carried out, through a non-experimental design. To evaluate the manual, 9 expert judges in psycho-oncology, intravenous therapy and medicine participated. Content validity was analyzed with the Osterlind index and reading difficulty with the INFLESZ index. Results: The manual obtained an excellent evaluation of its content with an Osterlind index of 0.88 and in the analysis of reading difficulty it obtained a score of 67.3, evidence of very easy-to-read material. Conclusions: The findings show that the developed manual is of quality, easy to access and understand for patients who will undergo central venous catheters. Likewise, evidence is offered of the importance of building educational materials based on research and statistical indicators.(AU)

A Comparison of Techniques of Internal Jugular Vein Cannulation: Anatomical Landmark, Ultrasound Guided Pre-location, and Real-Time Ultrasound Guided.

OBJECTIVE: The objective of our study is to compare the success rate, duration, and incidence of complications of a right internal jugular vein (IJV) cannulation by using three different techniques. METHODOLOGY: A randomised controlled trial was conducted at a tertiary care teaching hospital. A total of 201 patients were randomly allocated to one of the following three groups (67 in each group). Techniques were categorised as anatomical landmark technique group (Group ALT), ultrasound guided pre-location group (Group USG-Pre), and real-time ultrasound-guided technique group (Group USG-RT). INTERVENTIONS: Central venous catheter insertion via three techniques. RESULTS: In 138 (73.01%) patients' IJV canulated in the first attempt, USG-RT, USG-Pre, and ALT were 51 (83.6%), 44 (72.1%), and 43 (64.2%), respectively. On the other hand, 37 (19.57%) patients were required in the second attempt, while only 14 (7.40%) patients were required in the third attempt for successful IJV cannulation. The success rates, as defined in our study, were only 138 (73%) as, in 51 (27%), we cannulated in more than a single attempt or switched to another technique. We found a significant difference in preparation time in all techniques as P-value <0.05, but no significant difference was found in venous access time, cannulation time, and duration of the procedure. CONCLUSIONS: Any technique can be used for IJV cannulation, but the most acceptable is the real-time US technique. However, no difference in the overall procedure time among all three techniques was noted, and no major incidence of complication was found.

Risk of infections related to endovascular catheters and cardiac implantable devices in hemodialysis patients.

Patients requiring dialysis are extremely vulnerable to infectious diseases. The high burden of comorbidities and weakened immune system due to uremia and previous immunosuppressive therapy expose the patient on dialysis to more infectious events than the general population. The infectious risk is further increased by the presence of endovascular catheters and implantable cardiologic devices. The former is generally placed as urgent vascular access for dialysis and in subjects requiring hemodialysis treatments without autogenous arteriovenous fistula. The high frequency of cardiovascular events also increases the likelihood of implanting indwelling implantable cardiac devices (CIED) such as pacemakers (PMs) and defibrillators (ICDs). The simultaneous presence of CVC and CIED yields an increased risk of developing severe prosthetic device-associated bloodstream infections often progressing to septicemia. Although, antibiotic therapy is the mainstay of prosthetic device-related infections, antibiotic resistance of biofilm-residing bacteria reduces the choice of infection eradication. In these cases, the resolution of the infection process relies on the removal of the prosthetic device. Compared to CVC removal, the extraction of leads is a more complex procedure and poses an increased risk of vessel tearing. As a result, the prevention of prosthetic device-related infection is of utmost importance in hemodialysis (HD) patients and relies principally on avoiding CVC as vascular access for HD and placement of a new class of wireless implantable medical devices. When the combination of CVC and CIED is inevitable, prevention of infection, mainly due translocation of skin bacteria, should be a mandatory priority for healthcare workers.

A Simple and Safe Method for Checking the Position of Central Venous Catheters-A New and Reliable Threshold for Right Atrial Swirl Sign in Microbubbles Tests.

Background: Central venous catheters (CVCs) are indispensable tools in intensive care and emergency medicine. CVC malpositions still occur frequently and can cause various complications leading to increased patient mortality. A microbubbles test (MBT) can be used to confirm correct CVC positioning. However, there is serious doubt regarding whether the currently applied threshold of a 2 s push-to-bubbles time (PTB time) for rapid atrial swirl sign (RASS) in an MBT is reliable and accurate. The aim of the present study was to prove the quality of a new threshold: 1 s. Methods: Consecutive patients who were admitted to the intensive care unit (ICU) in a German neurological specialist hospital from 1 March 2021 to 20 July 2022 were enrolled. After ultrasound-guided CVC insertion, an MBT was performed, PTB time was measured, and RASS was interpreted. Additionally, a chest X-ray (CXR) was requested to check CVC position. Results: A total of 102 CVCs (98% jugular and 2% subclavian) were inserted in 102 patients (38% female and 62% male; median age: 66 years). Negative RASS (PTB time > 1 s) was observed in 2 out of 102 patients, resulting in an echocardiographic malposition rate of 2.0%. CXR confirmed the echocardiographic results. After correcting CVC position in the initially malpositioned CVCs, the PTB time was <1 s (positive RASS). The MBT protocol took about 0.5 min on average, while the CXR results were all available within 30 min. Sensitivity, specificity, and positive and negative predictive value were each 100% for the detection of CVC malpositions via an MBT using a threshold of 1 s compared to CXR. Conclusions: A new threshold of a 1 s PTB time for RASS in an MBT could detect CVC malpositions with excellent quality compared to CXR. Since the MBT was fast and safe and could be performed at the bedside, we propose that an MBT with the new and reliable threshold of 1 s should be routinely used in patient care.