The risk of fatal bleeding complications in jugular catheterization in patients with coagulopathy: A retrospective analysis of death cases in closed claims and the Medical Accident Investigating System in Japan

Background To prevent recurrence of medical accidents, the Medical Accident Investigating System was implemented in October 2015 by the Japan Medical Safety Research Organization (Medsafe Japan) to target deaths from medical care that were unforeseen by the administrator. Medsafe Japan analyzed the 10 cases of central venous catheterization-related deaths reported in the system and published recommendations in March 2017. However, the particular emphasis for the prevention of central venous catheterization-related deaths is unclear. Methods This study aimed to identify the recommendation points that should be emphasized to prevent recurrence of central venous catheterization-related deaths. We assessed central venous catheterization in 8530 closed-claim cases between January 2002 and December 2016 covered by the medical insurer Sompo-Japan. Moreover, we compared central venous catheterization-related death in closed-claim cases with death in reported cases. Results The background, error type, anatomic insertion site, and fatal complication data were evaluated for 37 closed-claim cases, of which 12 (32.4%) were death cases. Of the 12 closed-claim cases and 10 reported cases, 9 (75.0%) closed-claim cases and 9 (90.0%) reported cases were related to vascular access. Among these, 5 closed-claim cases (41.7%) and 7 reported cases (77.8%) were related to internal jugular vein catheterization (p = 0.28). Coagulopathy was observed in 3 (60.0%) of 5 closed-claim cases and 6 (85.7%) of 7 reported cases. Conclusions The risk of internal jugular catheterization in patients with coagulopathy must be carefully considered.

Axillary vein catheterization using ultrasound guidance: A prospective randomized cross-over controlled simulation comparing standard ultrasound and new needle-pilot device

Background: Real-time ultrasound (US) guidance facilitates central venous catheterization in intensive care unit (ICU). New magnetic needle-pilot devices could improve efficiency and safety of central venous catheterization. This simulation trial was aimed at comparing venipuncture with a new needle-pilot device to conventional US technique. Methods: In a prospective, randomized, simulation trial, 51 ICU physicians and residents cannulated the right axillary vein of a human torso mannequin with standard US guidance and with a needle-pilot system, in a randomized order. The primary outcome was the time from skin puncture to successful venous cannulation. The secondary outcomes were the number of skin punctures, the number of posterior wall puncture of the axillary vein, the number of arterial punctures, the number of needle redirections, the failure rate, and the operator comfort. Results: Time to successful cannulation was shorter with needle-pilot US-guided technique (22 s (interquartile range (IQR) = 16–42) vs 25 s (IQR = 19–128); median of difference (MOD) = −9 s (95%-confidence interval (CI) −5, −22), p < 0.001). The rates of skin punctures, posterior wall puncture of axillary vein, and needle redirections were also lower ( p < 0.01). Comfort was higher in needle-pilot US-guided group on a 11-points numeric scale (8 (IQR = 8–9) vs 6 (IQR = 6–8), p < 0.001). Conclusions: In a simulation model, US-guided axillary vein catheterization with a needle-pilot device was associated with a shorter time of successful cannulation and a decrease in numbers of skin punctures and complications. The results plea for investigating clinical performance of this new device.

Transition from epoprostenol to selexipag in a patient with systemic sclerosis and pulmonary hypertension during the postoperative period of colon cancer surgery: A case report

Introduction: Most pulmonary vasodilators are administered orally; however, in patients with pulmonary hypertension undergoing gastrointestinal surgery, a switch to parenteral drugs is needed. Parenteral pulmonary vasodilators carry a risk of infection and reduced quality of life owing to long-term central venous catheterization; therefore, it is preferable to switch them to oral vasodilators after surgery. Here, we present the case of a patient with systemic sclerosis complicated by pulmonary hypertension and colon cancer, for which treatment was successfully switched from epoprostenol to selexipag postoperatively. Case Description: A 59-year-old woman, who was diagnosed with mixed group I and III pulmonary hypertension and systemic sclerosis, was on oral triple pulmonary vasodilators for pulmonary hypertension and Raynaud’s phenomenon. She was diagnosed as having colon cancer 3 months before admission. Despite the severe pulmonary condition and treatment with oral triple pulmonary vasodilators, colon cancer resection surgery was performed with the management for pulmonary hypertension through multidisciplinary treatments in collaboration with cardiology specialists. Medications for patients with pulmonary hypertension undergoing gastrointestinal surgery need to be switched from oral vasodilators to epoprostenol perioperatively. On postoperative day 19, 0.4 mg/day of selexipag was administered with epoprostenol. Subsequently, the epoprostenol dosage was gradually decreased, and selexipag was increased. On postoperative day 30, the dose of selexipag was increased to 1.2 mg/day and epoprostenol was discontinued. The patient was discharged on postoperative day 40. Conclusion: In our case, transition from epoprostenol to selexipag contributed to a more useful management strategy for systemic sclerosis and pulmonary hypertension in the postoperative period.

Unusual complications of the central venous catheterization in trauma patients

Central venous catheters (CVCs) are commonly used in patients with trauma. The placement and removal of the CVCs can result in various complications regardless of the skill of the professionals. Herein, two cases of rare complications are presented— an inadvertent subclavian artery catheterization and a cerebral air embolism after a CVC removal. Moreover, practical solutions for each complication are provided in detail.

The need for multiple vascular access or preemptive central venous catheterization in patients requiring planned interhospital helicopter transport: a flight doctor’s suggestion

Hemorrhagic shock can develop due to severe bleeding, such as after major trauma, postpartum or gastrointestinal bleeding. At least two peripheral intravenous routes with large-bore catheters are recommended to reverse hemorrhagic shock, and such functional intravenous routes are essential for the proper management of other concurrent diseases as well. Conditions during helicopter transportation are different from those seen in-hospital, and the primary concerns are to maintain aseptic conditions, protect patient’s privacy, and prevent infection risk, especially during pandemics, such as the ongoing COVID-19. Herein, I describe two recent experiences of improper management during helicopter transport due to intravenous line malfunction. Subsequently, based on my experience, I suggest the use of multiple intravenous routes or preemptive central catheterization in patients requiring helicopter transportation.

The Use of a Disposable Umbilical Clamp to Secure an Umbilical Venous Catheter in Neonatal Emergencies—An Experimental Feasibility Study

Recent guidelines recommend the umbilical venous catheter (UVC) as the optimal vascular access method during neonatal resuscitation. In emergencies the UVC securement may be challenging and time-consuming. This experimental study was designed to test the feasibility of new concepts for the UVC securement. Umbilical cord remnants were catheterized with peripheral catheters and secured with disposable umbilical clamps. Three different securement techniques were investigated. Secure 1: the disposable umbilical clamp was closed at the level of the inserted catheter. Secure 2: the clamp was closed at the junction of the catheter and plastic wings. Secure 3: the setting of Secure 2 was combined with an umbilical tape. The main outcomes were the feasibility of fluid administration and the maximum force to release the securement. This study shows that inserting peripheral catheters into the umbilical vein and securing them with disposable umbilical clamps is feasible. Rates of lumen obstruction and the effectiveness of the securement were superior with Secure 2 and 3 compared to Secure 1. This new approach may be a rewarding option for umbilical venous catheterization and securement particularly in low-resource settings and for staff with limited experience in neonatal emergencies. However, although promising, these results need to be confirmed in clinical trials before being introduced into clinical practice.

Right Atrial Thrombus Associated with Central Venous Catheter after Surgical Repair of Co-arctation of Aorta

Central venous catheterization (CVC) is a routine and essential procedure performed in patients undergoing cardiac surgery. However, its use is not without complications ranging from mechanical to infectious to thrombotic in nature. Catheter-related right atrial thrombosis (CRAT) is usually underreported as it is commonly small in size and asymptomatic. Nevertheless, CRAT might lead to a potentially severe and life threatening complication in both adult and young patients. Up to 30% of patients with CVCs are estimated to be affected by CRAT. Anticoagulation and subsequently catheter removal were recommended as a first-line therapy and have suggested that no intervention may be associated with a high mortality rate. Here, we report a case of a 3-months-old male child who underwent coarctation of aorta repair and was diagnosed with right atrial thrombosis associated with CVC in postoperative period and anticoagulated with unfractionated heparin. The thrombus was followed up closely and when there was no further decrease in the size of the mass around 9 days after the diagnosis, the CVC was removed. The heparin was continued even after removal of CVC for further 7 days and patient was eventually discharged from the hospital.