Platypnea–orthodeoxia syndrome in a postoperative patient: a case report

Background We report a case of platypnea–orthodeoxia syndrome observed in a complex clinical situation associating a bilateral pleural effusion, lobar pulmonary embolism, and a partial anomalous pulmonary venous return. Case presentation A 57-year-old Caucasian woman developed acute dyspnea in the postoperative course of an elective gynecological surgery for advanced stage ovarian cancer. Preoperative evaluation had failed to reveal any respiratory or cardiac problem. After evidence of a low arterial oxygen saturation, blood gas analysis from the central venous line correctly inserted in the right internal jugular vein revealed a higher oxygen saturation than in the arterial compartment. A thoracic computed tomography showed bilateral pleural effusion, lobar pulmonary embolism, and a drainage of a left pulmonary vein into the left innominate vein. This unique combination resulted in an uncommon cause of platypnea–orthodeoxia syndrome. Conclusion Often associated with right-to-left shunting, platypnea–orthodeoxia syndrome may be observed in complex clinical conditions with several factors influencing the ventilation/perfusion ratio. The paradoxical finding of a higher oxygen saturation in a central venous line than in an arterial line should prompt the clinician to look at the possibility of partial anomalous pulmonary venous return. No specific treatment is required in asymptomatic adults, except for an echocardiographic follow-up to detect the onset of pulmonary hypertension.

Modified Seldinger technique for internal jugular open central venous line insertion in neonates: merging two different manoeuvers

Background Central venous line insertion in neonates is an important and lifesaving procedure. It can carry significant risks and complications, including death, at the time of insertion or later. We aimed to retrospectively assess the modified Seldinger technique for open placement of a central venous catheter in neonates, regarding its safety, feasibility, operative time, and preservation of the patency of the internal jugular vein. This study was conducted on 120 neonates from March 2018 to March 2020. We closely monitored the pulse for the detection of arrhythmia or bradycardia, which might be caused during the insertion of the guide wire or the tip of the catheter. Post-operative X-ray was done immediately after the end of the procedure for all cases, to determine the site of the central venous catheter and to detect the presence of pneumothorax. Results Arrhythmia was observed in 9 cases (7.5%), and blood oozing in 5 cases (4.1%). There were 3 cases of pneumothorax (2.5%), 2 cases of neck hematoma in two cases (1.6%), 6 cases of internal jugular vein thrombosis (5%), and dislodging of the catheter in 3 cases (2.5%). There were no cases of arterial puncture, failure of cannulation, or haemothorax in our study. Conclusions The modified Seldinger technique insertion for open central venous line in neonates is a safe, accessible, and feasible method, especially in centers that lack the experience of ultrasound-guided insertion in neonates.

Comparison of the Efficacy of Simple, Partial Manual and Automated Exchange Transfusions in the Management of Sickle Cell Disease in Pediatric Patients

Background: Chronic transfusion therapy in sickle cell disease is used to prevent complications of sickle cell disease by reducing hemoglobin S levels, most commonly used for primary or secondary stroke prophylaxis, amongst other indications. Transfusions can be completed as simple, partial manual exchange or automated exchange.Comparative evidence on the long term efficacy of simple, partial manual or automated exchange in the management of children with sickle cell disease is lacking. Methods: A retrospective study of patients aged less than 18 years with a diagnosis of sickle cell disease on a chronic transfusion program (simple top-up transfusion, partial manual exchange or automated exchange transfusion), followed at the Hospital for Sick Children, Toronto, Ontario from January 2003- July 2020.We excluded patients who received transfusions for acute complications. Data collected included: demographics, indication for transfusion, type of transfusion (simple, partial manual exchange or automated exchange), access for transfusion (peripheral intravenous (PIV), central venous line (CVL)), pre-transfusion hemoglobin and hemoglobin S values. Analysis: Exploratory data analysis was conducted where descriptive statistics were used to summarize data for both continuous and categorical variables. Continuous variables were summarized using measures of central tendency and dispersion where mean and standard deviations for normally distributed data and medians and interquartile ranges were used where the data was skewed. Chi-squared tests were employed when demonstrating relationships between two categorical variables. All statistical analyses were two-sided tests with 0.05 as the critical level of significance. Ethics: This study was approved by The Hospital of Sick Children Research Ethics Board(REB). Results: Sixty-one participants were observed between January 2003 and July 2020. Majority 38 out of (62.3%) of the participants were male. The most common indication for transfusion was primary stroke prevention (following abnormal transcranial doppler (TCD) 36 %) followed by vasculopathy 11 (%, stroke 9 % , abnormal TCD & silent infarct 8 %, and splenic sequestration 2 %) There were 744 total transfusions. 491/744 (66%) transfusions were simple transfusions, 168/744 (22.6%) were PMEs while 85/744 (11.4%) were apheresis transfusions. Average pre-transfusion hemoglobin S (HbS) was similar between the two types of access (p=0.416) and also across the three types of transfusion (p=0.158). The type of access did not appear to have an effect on the changes in HbS per transfusion(p=0.561.) The trends of pre-transfusion HbS %were similar over time between participants whose access was PIV and those whose access was CVL/ PORT.(Figure 1 below). Achievement of target HbS was similar between peripheral intravenous and central venous line access (p=0.337) and across the three types of transfusion (p=0.086).See Table 1 below. The type of transfusion had an effect on the reduction in HBS with simple transfusion having the highest percentage change of HbSS(-3.69%) followed by Apheresis (-1.32%) and PME (-0.75%), p=0.018., that is per every transfusion. The reason for this is that is the values being compared are quite different. The automated exchange values are on established patients (pre transfusion hemoglobin S had already been lowered), while the simple transfusion values are on new to transfusion patients (pre transfusion S high), the patients on partial manual exchange started off with lower HbS levels, so consequently their change was less. Conclusion: All three types of transfusion had equal efficiency in reducing HbS over time. Apheresis showed a quicker reduction in the hemoglobin S level in the initial transfusions. Simple transfusions and PME are as efficient as apheresis in achieving target HbS levels to prevent complications associated with SCD. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

60 Impact of sequential implementation of a standardized feeding protocol and donor breastmilk on necrotizing enterocolitis among preterm infants born <31 weeks gestation

Primary Subject area Neonatal-Perinatal Medicine Background Necrotizing enterocolitis (NEC) is the leading cause of gastrointestinal morbidity and mortality among preterm infants born &lt;31 weeks. Nutritional interventions such as a standardized feeding protocol (SFP) and donor breastmilk (DBM) are recommended to reduce NEC. Objectives Our objective was to assess the impact of implementing a feeding protocol and pasteurized donor breastmilk protocol on NEC among preterm infants born &lt; 31 weeks GA. Design/Methods Retrospective cohort study including 682 infants born &lt; 31 weeks, who survived ≥ 14 days and were admitted to two tertiary NICUs from 2009-2018. Data was obtained from the local Canadian Neonatal Network database. Infants were classified into epochs, based on the timing of interventions: Epoch 1, baseline (2009-2012); Epoch 2, SFP (2013-2015); Epoch 3, SFP + DBM (2016-2018). The primary outcome was NEC stage ≥ 2. Multivariable logistic regression models were used to assess associations between epochs and outcomes and were adjusted for confounders. Results Among 682 infants, 46 (7%) had NEC and 74 (11%) had mortality/NEC. Rates of NEC decreased with each epoch: 10% (25/246) Epoch 1 (baseline); 5% (8/163) Epoch 2 (SFP); and 5% (13/273) Epoch 3 (SFP+DBM), (p&lt;0.01) (Table1). SFP alone was associated with significantly lower odds of NEC compared to baseline (Epoch 2 vs 1, AOR 0.42, 95% CI 0.17-0.93) (Table 2). Implementation of DBM was not associated with lower odds of NEC compared to SFP alone (Epoch 3 vs 2, AOR 0.94, 95% CI 0.38-2.42) (Table2). Number of NPO days prior to the initiation of enteric feeds after birth decreased in Epoch 3 (Epoch 1&2: 2 days versus Epoch 3: 1 day; p&lt;0.01). Exclusive human breastmilk feeds during the first 3 weeks increased from 62% in Epoch 2 to 82% in Epoch 3 (p&lt;0.01). A significant decrease in number of total parenteral nutrition and central venous line (CVL) days was observed from Epoch 1 to 3 (25 to 15 days and 26 to 15 days respectively; p&lt;0.01) (Table 1), this was reflected in the decrease in late onset sepsis (Epoch 3 vs 1, AOR 0.55, 95% CI 0.35-0.86). Conclusion Implementation of SFP was associated with a significant decrease in NEC among infants born &lt; 31 weeks. Combining the SFP and DBM did not further decrease NEC, but was associated with shorter NPO days, higher exclusive human breastmilk exposure, and significant decrease in number of central venous line (CVL) days.

74 Central venous line-related thrombosis in neonates: A population-based study

Primary Subject area Neonatal-Perinatal Medicine Background The incidence of central venous line (CVL)-related thromboembolism (TE) in neonates is rising dramatically. The mainstay of treatment in neonatal thrombosis is anticoagulant therapy. However, management of neonatal CVL-related TE is particularly complex, as the higher risk of systemic and intracranial bleeding, especially in premature babies, must be balanced with the thrombotic risks, including death, or morbidity such as organ dysfunction, post-thrombotic syndrome, and neurodevelopmental sequelae. There is a paucity of evidence regarding the epidemiology of neonatal CVL-related thrombosis, to help clinicians identify neonates at high-risk of CVL-related thrombosis, as well as to tailor treatment based on the risks and benefits of anticoagulants in neonates. Objectives The objectives of this retrospective cohort study are: 1) to determine the main risk factors of CVL-related TE in neonates admitted to the neonatal intensive care unit (NICU); and 2) to compare the effectiveness and safety between different antithrombotic treatment modalities for neonatal CVL-related TE using the Canadian Neonatal Network (CNN) database and electronic medical chart review. Design/Methods Neonates ≤ 28 days of life admitted to the NICU for ≥ 24 hours requiring a CVL with TE confirmed by imaging were included in the study. The main effectiveness outcome is the resolution of TE, whereas the main safety outcome is the apparition of a major bleeding. In this study (n=39), we compared the effectiveness and safety outcomes according to antithrombotic treatment modalities (conservative vs. anticoagulation). Results The median gestational age is 35[26-38] weeks, and the mean birth weight is 2096±1110 g. CVL responsible for TE was umbilical venous catheter (28%), umbilical arterial catheter (46%), peripherally inserted central catheter (PICC line) (8%), and peripheral arterial catheter (18%). The anticoagulation therapy is more effective to achieve a partial and complete resolution of TE than the conservative treatment after a mean follow-up of 7 weeks (p=0.02). However, there were no differences according to antithrombotic treatment group regarding safety outcome assessed by major bleedings (p=0.2). Conclusion Our results tend to suggest that anticoagulation therapy is more effective to achieve resolution of CVLs-related TE than conservative treatment without compromising the safety of neonates. However, a large multicentric study is required to evaluate the risks and benefits of anticoagulants in neonates.

Appearance can be Deceptive- A Case Report on Central Venous Line Complication

Central venous (CV) lines are widely used for anything from rapid fluid resuscitation, to drug administration, to parenteral nutrition, and even for administering hemodialysis. Central lines come in different sizes, types, and sites of administration. Sometimes their use can be associated with complications as well. Our patient is an 85 years old hypertensive, diabetic female presenting with post COVID fibrosis with aspiration pneumonia with septic shock. After admissions in ICU, CV line was inserted through right sub-clavian venous route for administration of essential medications including inotropes. However, forceful backflow of blood was noticed after insertion of CV line raising the suspicion of arterial insertion. It was later confirmed by CXR, ABG and duplex arterial study. Taking appropriate precautions, we were able to remove the CV line safely without any complications. Sometimes minor and easy things like CV like insertion can become life threatening. But with proper knowledge and planning we can overcome any complications. Cardiovasc j 2021; 14(1): 73-75

Subclavian vein injury during placement of the right internal jugular dialysis catheter

We present a case of a serious complication during placement of a tunneled central venous line due to rupture of the right subclavian vein and subsequent right hemothorax and hemomediastinum that warranted surgical intervention. The surgery was successful, however, the patient died of multiple comorbidities and multiorgan failure 4 days later.

Occurrence and Severity of Venous Air Embolism During Neurosurgical Procedures in Semi-Sitting Versus Supine Position

Background: Patients undergoing neurosurgical procedures in the posterior cranial fossa can be placed in different positions: the semi-sitting position or the supine position. The major risk of the semi-sitting positioning is venous air embolism (VAE). However, VAEs may also occur in the supine position.Objective: In a prospective study, we investigated the incidence of VAE based on the positioning of the patients (trial registration 553/2013BO1).Methods: In a single-center study with 137 patients, we prospectively evaluated the occurrence of VAEs in patients in the supine and semi-sitting position over the period from January 2014 to April 2015. All patients were monitored for VAE by the use of a transesophageal echocardiography (TEE).Results: 50% of all participating patients experienced a VAE (with 56% of these patients undergoing surgery in the semi-sitting position and 11% in the prone position). 86% of the VAEs were just detected by the use of a TEE. We only observed VAEs with a decrease in EtCO2 in the semi-sitting position. However, none of the patients had any hemodynamic changes due to the VAE. We found that surgeries in patients with a preexisting intracardial shunt such as a patent foramen ovale (PFO) less likely resulted in VAEs (42% vs. 58%).Conclusion: The semi-sitting position with TEE monitoring and a standardized protocol, including a deep central venous line is a safe and advantageous technique, taking also account of a significant rate of VAEs. VAEs also occur in the supine position, however, less frequently.