Central venous catheter tip misplacement: A multicentre cohort study of 8556 thoracocervical central venous catheterisations.

BACKGROUND: There is a paucity of data on the incidence of central venous catheter tip misplacements after the implementation of ultrasound guidance during insertion. The aims of the present study were to determine the incidence of tip misplacements and to identify independent variables associated with tip misplacement. METHODS: All jugular and subclavian central venous catheter insertions in patients ≥16 years with a post-procedural chest radiography at four hospitals were included. Each case was reviewed for relevant catheter data and radiologic evaluations of chest radiographies. Tip misplacements were classified as 'any tip misplacement', 'minor tip misplacement' or 'major tip misplacement'. Multivariable logistic regression analyses were used to investigate associations between predefined independent variables and tip misplacements. RESULTS: A total of 8556 central venous catheter insertions in 5587 patients were included. Real-time ultrasound guidance was used in 91% of all insertions. Any tip misplacement occurred (95% confidence interval) in 3.7 (3.3-4.1)% of the catheterisations, and 2.1 (1.8-2.4)% were classified as major tip misplacements. The multivariable logistic regression analyses showed that female patient gender, subclavian vein insertions, number of skin punctures and limited operator experience were associated with a higher risk of major tip misplacement, whereas increasing age and height were associated with a lower risk. CONCLUSIONS: In this large prospective multicentre cohort study, performed in the ultrasound-guided era, we demonstrated the incidence of tip misplacements to be 3.7 (3.3-4.1)%. Right internal jugular vein catheterisation had the lowest incidence of both minor and major tip misplacement.

Operator gender differences in major mechanical complications after central line insertions: a subgroup analysis of a prospective multicentre cohort study.

BACKGROUND: A previous study on mechanical complications after central venous catheterisation demonstrated differences in complication rates between male and female operators. The objective of this subgroup analysis was to further investigate these differences. The hypothesis was that differences in distribution of predefined variables between operator genders could be identified. METHODS: This was a subgroup analysis of a prospective, multicentre, observational cohort study conducted between March 2019 and December 2020 including 8 586 patients ≥ 16 years receiving central venous catheters at four emergency care hospitals. The main outcome measure was major mechanical complications defined as major bleeding, severe cardiac arrhythmia, pneumothorax, arterial catheterisation, and persistent nerve injury. Independent t-test and χ2 test were used to investigate differences in distribution of major mechanical complications and predefined variables between male and female operators. Multivariable logistic regression analysis was used to determine association between operator gender and major mechanical complications. RESULTS: Female operators had a lower rate of major mechanical complications than male operators (0.4% vs 0.8%, P = .02), were less experienced (P < .001), had more patients with invasive positive pressure ventilation (P < .001), more often chose the internal jugular vein (P < .001) and more frequently used ultrasound guidance (P < .001). Male operators more often chose the subclavian vein (P < .001) and inserted more catheters with bore size ≥ 9 Fr (P < .001). Multivariable logistic regression analysis showed that male operator gender was associated with major mechanical complication (OR 2.67 [95% CI: 1.26-5.64]) after correction for other relevant independent variables. CONCLUSIONS: The hypothesis was confirmed as differences in distribution of predefined variables between operator genders were found. Despite being less experienced, female operators had a lower rate of major mechanical complications. Furthermore, male operator gender was independently associated with a higher risk of major mechanical complications. Future studies are needed to further investigate differences in risk behaviour between male and female operators. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT03782324. Date of registration: 20/12/2018.

Major immediate insertion-related complications after central venous catheterisation and associations with mortality, length of hospital stay, and costs: A prospective observational study.

BACKGROUND: It is well-known that infectious complications after central venous catheterisation are associated with increased mortality, length of hospital stay and costs. However, there are limited data regarding such associations for immediate insertion-related complications. Therefore, the aim of this study was to investigate whether major immediate insertion-related complications are associated with mortality, length of hospital stay and costs. METHODS: This was a preplanned substudy to the CVC-MECH trial on immediate insertion-related complications after central venous catheterisation in the ultrasound-guided era. Patients receiving central venous catheters at Skåne University Hospital from 2 March 2019 to 31 December 2020 were prospectively included. Patient characteristics, clinical data and costs were automatically collected from medical journals and the patient administration system. Associations between major immediate insertion-related complications and mortality, length of hospital stay and costs were studied by multivariable logistic and linear regression analyses. RESULTS: In total, 6671 patients were included, of whom 0.5% suffered major immediate insertion-related complications. Multivariable analyses, including surrogates for general morbidity, showed associations between major immediate insertion-related complications and 30-day (odds ratio 2.46 [95% CI 1.05-5.77]), 90-day (2.90 [1.35-6.21]) and 180-day (2.26 [1.05-4.83]) mortality. There were no associations between major immediate insertion-related complications and increased length of hospital stay or costs. CONCLUSION: This study showed that major immediate insertion-related complications, although not directly responsible for any death, were associated with increased 30-day, 90-day and 180-day mortality. These findings clearly demonstrate the importance of using all possible means to prevent avoidable insertion-related complications after central venous catheterisation.

Radiographic Study of Transcrestal Sinus Floor Elevation Using Osseodensification Technique with Graft Material: A Pilot Study.

This pilot study aimed to evaluate the level of implant success after transcrestal sinus floor elevation (tSFE) using the osseodensification technique (OD) combined with beta-tricalcium phosphate (ß-TCP) by analyzing clinical and radiographic results. Moreover, the increase in bone height was analyzed immediately after surgery, 3 months after, and before loading by taking standardized radiographic measurements. Thirteen patients, four males and nine females, with a mean age of 54.69 ± 5.86 years, requiring the placement of one implant in the upper posterior maxilla, with a residual bone height of <8 mm and a minimum bone width of 5 mm, participated in the study. The bone gain data was obtained using cone-beam computed tomography (CBCT) immediately after surgery and twelve months after the placement. The correlation between initial and final bone height with implant stability was also assessed. The results were analyzed using SPSS 23 software (p < 0.05). The results of the study indicated a 100% implant success rate after a follow-up period of twelve months. Preoperative main bone height was 5.70 ± 0.95 mm. The osseodensification technique allowed a significant increase of 6.65 ± 1.06 mm immediately after surgery. After a twelve-month follow-up, a graft material contraction of 0.90 ± 0.49 mm was observed. No correlation was observed between the bone height at the different times of the study and the primary stability of the implant. Considering the limitations of the size sample of this study, the osseodensification technique used for transcrestal sinus lift with the additional bone graft material (ß-TCP) may provide a predictable elevation of the maxillary sinus floor, allowing simultaneous implant insertion with adequate stability irrespective of bone height limitations.

Ultrasound-guided subclavian vein catheterisation with a needle guide (ELUSIVE): protocol for a randomised controlled study.

INTRODUCTION: Central venous catheters are indispensable in modern healthcare. Unfortunately, they are accompanied by minor as well as major complications, leading to increased morbidity, mortality and costs. Immediate insertion-related complications (mechanical complications) have decreased due to the implementation of real-time ultrasound guidance, but they still occur and additional efforts to enhance patient safety are warranted. This study aims to investigate whether the use of a needle guide mounted on the ultrasound probe in subclavian catheterisations may decrease the number of catheterisations with >1 skin puncture (primary outcome). METHODS AND ANALYSIS: This is an investigator-initiated, non-commercial, randomised, controlled, parallel-group study conducted at Skåne University Hospital, Lund, Sweden. Adults (≥18 years) with a clinical indication for a subclavian central venous catheter and the ability to give written informed consent will be eligible for inclusion. Exclusion criteria include subclavian catheterisation deemed unsuitable based on the preprocedural ultrasound examination. Patients will be randomised to catheterisation by certified operators using a microconvex probe (long-axis, in-plane technique) with (n=150) or without (n=150) a needle guide. The ultrasound imaging from the procedures will be recorded and assessed by two reviewers individually. The assessors will be blinded for group affiliation. Secondary outcomes include the total number of skin punctures, mechanical complications, time to successful venous puncture, number of failed catheterisations and operator satisfaction with the needle guide at the end of the study period.Recruitment started on 8 November 2022 and will continue until the sample size is achieved. ETHICS AND DISSEMINATION: This study was approved by the Swedish Ethical Review Authority (#2022-04073-01) and the Swedish Medical Products Agency (#5.1-2022-52130; CIV-21-12-038367). The findings will be submitted to an international peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT05513378, clinicaltrials.gov.

Evaluation of the primary stability in dental implants placed in low density bone with a new drilling technique, Osseodensification: an in vitro study / Evaluación de la estabilidad primaria en implantes dentales colocados en baja densidad hueso con una nueva técnica de perforación, Osteodensificación: un estudio in vitro

Background: Primary stability is an important key determinant of implant osseointegration. We investigated ap-proaches to improve primary implant stability using a new drilling technique termed osseodensification (OD),which was compared with the conventional under-drilling (UD) method utilized for low-density bones.Material and Methods: We placed 55 conical internal connection implants in each group, in 30 low-density sec-tions of pig tibia. The implants were placed using twist drill bits in both groups; groups Under Drilling (UD)and Osseodensification (OD) included bone sections subjected to conventional UD and OD drilling, respectively.Before placing the implants, we randomized the bone sections that were to receive these implants to avoid samplebias. We evaluated various primary stability parameters, such as implant insertion torque and resonance fre-quency analysis (RFA) measurements.Results: The results showed that compared with implants placed using the UD technique, those placed using theOD technique were associated with significantly higher primary stability. The mean insertion torque of the im-plants was 8.87±6.17 Ncm in group 1 (UD) and 21.72±17.14 Ncm in group 2 (OD). The mean RFA was 65.16±7.45ISQ in group 1 (UD) and 69.75±6.79 ISQ in group 2 (OD).Conclusions: The implant insertion torque and RFA values were significantly higher in OD group than in UD.Therefore, compared with UD, OD improves primary stability in low-density bones (based on torque and RFAmeasurements).(AU)

Terapia antihipertensiva e insuficiencia cardíaca congestiva. Réplica / Antihypertensive therapy and congestive heart failure. Author´s reply

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