ULTRASOUND GUIDED CENTRAL VENOUS CANNULATION BY ANESTHESIA TRAINEE: NEED OF THE HOUR DURING COVID PANDEMIC

Covid pandemic has created deciency of doctors needed to administer skilled procedures in ICUs and operating rooms. Post graduate trainees need to acquire skills fast and perform it safely on patients. Ultrasound (USG)-guided central venous cannulation (CVC) is one such. The study aimed at nding the feasibility of training USG-guided CVC cannulation to anesthesia trainee as opposed to landmark method in terms of ease, speed and safety. Patients needing CVC were divided into 2 groups of 50 each, where Group 1 was subjected to Landmark method and Group 2 to USG-guided method. Continuous variables were compared using unpaired t test and categorical variables using either the Chi square test. Access time (in seconds) was signicantly less in the USG group (258.78 ± 11.17) as opposed to Landmark technique (301.60 ± 14.03) (p 0.03). Accidental carotid artery puncture was seen in 9 patients in Landmark group as opposed to none in the USG group. No patient in any group developed pneumothorax. USG-guided technique is superior and safer than the traditional landmark technique in hands of anaesthesia trainee in terms of a shorter access time, and less incidence of arterial puncture which is desirable in COVID patients to shorten the exposure time. USG-guided method needs an assistant to focus the probe. Nonetheless, this training should be imparted to the trainee to ll the gap created by skilled doctors falling sick during COVID pandemic.

Practical procedures

This chapter assesses the practical procedures in surgery. It begins with airway procedures, including the anaesthesia face mask, laryngeal mask airway (LMA), and endotracheal intubation. It also looks at percutaneous dilatational tracheostomy (PDT) and cricothyroidotomy, before differentiating between non-invasive and invasive ventilation. The chapter then turns to circulation procedures, including venepuncture and intravenous cannulation; interosseous access; central venous cannulation; arterial puncture and arterial cannulation; cardioversion; and defibrillation. It also considers the insertion and management of chest drain, which is used to drain pneumothoraces or pleural effusions. Finally, the chapter deals with pericardiocentesis; nasogastric tube insertion; urethral and suprapubic catheterisation; abdominal paracentesis; rigid sigmoidoscopy; and local and regional anaesthesia.

The Venerable Subclavian Line

In this treatise, we will address one of the higher-risk procedures, subclavian vein cannulation, that a practitioner may undertake in the care of complex patients. All cardiothoracic surgeons and their trainees will need, on occasion, to put in central lines in a variety of circumstances, including in the operating room, in the intensive care unit, in emergency circumstances, and, occasionally, when other practitioners have been unsuccessful in their attempts to place a central line. We will describe, in detail, the anatomy of the subclavian vein, the preparation of the patient for subclavian vein cannulation, the infraclavicular approach to cannulation of the vein, and a few notes about the supraclavicular approach to the subclavian vein. It is self-evident that the priorities of central venous cannulation include safety of insertion, minimizing clot formation, and avoiding infection. We will dwell primarily on the principles of safe subclavian line insertion.

Microbiological profiles and prognostic factors of infection mortality in febrile neutropenic children with malignancy

Background Post-chemotherapy febrile neutropenia results in high morbidity and mortality in children with malignancy. Many prognostic factors, such as microorganism patterns, as well as the use of antibiotics and antifungals can affect the outcomes. However, limited study is available in Indonesia. Objective To determine the microbial profiles, antibiotic sensitivity, and other factors that influence mortality from febrile neutropenia in pediatric malignancies with infections. Methods This retrospective cohort and descriptive study of 180 children with 252 episodes of neutropenic fever was done in Cipto Mangunkusumo Hospital, Jakarta, between 2015 and 2017. Medical history of possible predictive prognostic factors, including microorganism patterns and antibiotic sensitivity, were recorded. Prognostic factors were analyzed using multivariate logistic regression tests. Results The most common bacteria was Gram-negative (54.5%), while Candida sp. was the most common fungal infection (82.5%). Klebsiella sp. was mainly sensitive to amikacin (85.71%), while Pseudomonas aeruginosa was sensitive to ceftazidime (75%), as well as amikacin and gentamicin (100% sensitivity in combination). Staphylococcus sp. was mainly sensitive to amoxi-clav and ampi-sulbactam (76.9%). Almost all fungal groups were susceptible to fluconazole, ketoconazole, voriconazole (80-100%). Prognostic factors that increased mortality risk were central venous cannulation (RR 1.947; 95%CI 1.114 to 3.402), wasting (RR 1.176; 95%CI 1.044 to 1.325), severe wasting (RR 1.241; 95%CI 0.975 to 1.579), and hematologic malignancies (RR 0.87; 95%CI 0.788 to 0.976). Conclusion Central venous cannulation and wasting are significant prognostic factors of increased mortality in children with febrile neutropenia. Gram negative bacteria along with Candida sp. is the most common pathogen in such condition.

Dilated internal mammary veins in liver disease – A potential pitfall in central venous cannulation

Introduction: Portal hypertension leads to dilation of internal mammary veins. Among the various sites of misplacement of a catheter inserted via the internal jugular vein, misplacement in the internal mammary vein is relatively rare in the general population, when compared to liver disease patients. Catheter misplacement during central venous cannulation can be associated with thrombosis, wedging, erosion, and perforation. The option of replacing or removing the catheter is not always risk-free, particularly with associated coagulopathy. We describe the management of a misplaced CVC which was accessed through the left internal jugular vein and repositioned under fluoroscopic guidance. Keywords: Central venous catheter, Repositioning of central venous catheter, central venous catheter in left internal mammary vein, portal hypertension, fluoroscopy