Venous cannulation and topical ethyl chloride in patients receiving nitrous oxide.
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The purpose of this study was to evaluate the effect of ethyl chloride spray on the anxiety and pain associated with placing an intravenous catheter in patients sedated with nitrous oxide. Eighty-eight patients scheduled for dental surgery with a combination of intravenous and nitrous oxide sedation were randomly assigned to have ethyl chloride spray or a placebo, water spray, applied before cannulation of a vein. Anxiety and pain were reported using a 10.0-cm visual analog scale before nitrous oxide administration, after nitrous oxide sedation, following application of the spray, and following venous cannulation. The first 2 assessments measured overall levels of patient anxiety and pain and confirmed that nitrous oxide sedation reduced anxiety without changing already low levels of pain. The second 2 assessments of anxiety and pain measured the reaction toward the spray and cannulation. The application of ethyl chloride spray produced significantly more anxiety and pain than did the placebo. The results of this study demonstrate that ethyl chloride spray does not significantly reduce the anxiety and pain associated with venous cannulation in patients sedated with nitrous oxide. (+info)
Ultrasound guided human thrombin injection. A new modality in the management of femoral artery pseudo-aneurysms.
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OBJECTIVES: We report our initial results of a prospective study of duplex ultrasound-guided injection (UGTI ) of thrombin in the management of femoral artery pseudo-aneurysms. We used human thrombin to avoid the increase in the human antibodies directed against fibrinogen, with the use of bovine thrombus, that preclude further utilisation of the bovine fibrin glue during cardio-thoracic surgery. METHODS: From 1999 to 2001, 19 patients, aged 69 (range 52-85) years presented with 21 femoral pseudo-aneurysms were treated. The mean pseudoaneurysm diameter was 30 (15-55) mm. All but two were secondary to cardiac procedures and the common femoral artery was the injured vessel in all instances. Patients were referred within 2-21 days following their iatrogenic injury. RESULTS: Immediate thrombosis of the sac occurred in 19 (90%) of the 21 pseudo-aneurysms. After a second injection, complete occlusion occurred in the remaining two patients. Two patients (CI 95%; 1-19) with three femoral pseudo-aneurysms developed leg pain. Duplex ultrasound follow-up showed two recurrences (9.5% - CI 95%; 1-19) and both were treated by repeat UGTI. There was no conversion to surgical repair. CONCLUSION: This percutaneous minimally invasive technique is safe and effective in the management of iatrogenic pseudo-aneurysms in this high-risk group of patients. Human thrombin has significant advantages over bovine thrombin. (+info)
Surgical intervention for complications caused by femoral artery catheterization in pediatric patients.
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PURPOSE: This study evaluated the risk factors and surgical management of complications caused by femoral artery catheterization in pediatric patients. METHODS: From January 1986 to March 2001, the hospital records of all children who underwent operative repairs for complications caused by femoral artery catheterization were reviewed. A prospective cardiac data bank containing 1674 catheterization procedures during the study period was used as a means of determining risk factors associated with iatrogenic femoral artery injury. RESULTS: Thirty-six operations were performed in 34 patients (age range, 1 week-17.4 years) in whom iatrogenic complications developed after either diagnostic or therapeutic femoral artery catheterizations during the study period. Non-ischemic complications included femoral artery pseudoaneurysms (n = 4), arteriovenous fistulae (n = 5), uncontrollable bleeding, and expanding hematoma (n = 4). Operative repairs were performed successfully in all patients with non-ischemic iatrogenic femoral artery injuries. In contrast, ischemic complications occurred in 21 patients. Among them, 14 patients had acute femoral ischemia and underwent surgical interventions including femoral artery thrombectomy with primary closure (n = 6), saphenous vein patch angioplasty (n = 6), and resection with primary anastomosis (n = 2). Chronic femoral artery occlusion (> 30 days) occurred in seven patients, with symptoms including either severe claudication (n = 4) or gait disturbance or limb growth impairment (n = 3). Operative treatments in these patients included ileofemoral bypass grafting (n = 5), femorofemoral bypass grafting (n = 1), and femoral artery patch angioplasty (n = 1). During a mean follow-up period of 38 months, no instances of limb loss occurred, and 84% of children with ischemic complications eventually gained normal circulation. Factors that correlated with an increased risk of iatrogenic groin complications that necessitated surgical intervention included age younger than 3 years, therapeutic intervention, number of catheterizations (>or= 3), and use of 6F or larger guiding catheter. CONCLUSION: Although excellent operative results can be achieved in cases of non-ischemic complications, acute femoral occlusion in children younger than 2 years often leads to less satisfactory outcomes. Operative intervention can provide successful outcome in children with claudication caused by chronic limb ischemia. Variables that correlated with significant iatrogenic groin complications included a young age, therapeutic intervention, earlier catheterization, and the use of a large guiding catheter. (+info)
Treatment of postcatheterisation false aneurysms: ultrasound-guided compression vs ultrasound-guided thrombin injection.
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OBJECTIVES: to compare the efficacy and cost-effectiveness of ultrasound-guided compression (UGC) with ultrasound-guided thrombin injection (UGTI) for treatment of postcatheterisation arterial false aneurysms (cFA). DESIGN: prospective clinical study using historical controls. MATERIALS AND METHODS: we prospectively collected data on 33 consecutive patients diagnosed with cFA larger than 1.5 cm in diameter. These were treated with UGTI. We performed a retrospective review of data on a former group of 33 consecutive historical control patients that were treated by UGC. RESULTS: the groups were similar in respect of demographic and clinical variables. Thirty patients were suitable for UGC and 33 patients were suitable for UGTI. The success rate for UGC was 26/30 (87%) compared to 33/33 (100%) for UGTI (p<0.05). Thrombosis was achieved during the first treatment session in 7/26 patients treated by UGC, compared to 26/33 in the UGTI group (p<0.0001). Four patients that failed UGC and two patients that were unsuitable for UGC required surgical repair. UGTI as compared to UGC was shorter in duration (25 vs 75 min) and required no sedation. No thromboembolic or systemic complications occurred in either group. Cost analysis revealed savings of $US 517 for each patient treated by UGTI as compared with UGC. CONCLUSIONS: in our study, UGTI is superior to UGC, and we suggest that UGTI should become the procedure of choice for the treatment of cFA. (+info)
Successful use of topical nitroglycerine in ischaemia associated with umbilical arterial line in a neonate.
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Ischaemic changes associated with umbilical arterial cannulation is an important cause of neonatal morbidity in the NICU. We report successful use of topical nitroglycerine in an infant with ischaemic changes over the right buttock following insertion of an umbilical arterial catheter. (+info)
Rapid skin anaesthesia using high velocity lignocaine particles: a prospective placebo controlled trial.
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BACKGROUND: Local anaesthetic creams (EMLA and Ametop) are used widely to provide pain free intravenous cannulation. However, they take a minimum of 45 minutes to become effective. AIMS: To evaluate a prototype device, dermal Powderject lidocaine (DPL), that delivers high velocity lignocaine particles into the skin. METHODS: A total of 132 children (aged 4-12 years) were randomised to receive either a sham delivery or a delivery of DPL on the skin at the antecubital fossa, or back of hand. Pain of intravenous cannulation was assessed four minutes later using self reporting behaviours and blinded observation with standard pain assessment tools. The trial was designed to measure both efficacy of skin anaesthesia and potential skin damage with increasing driving pressure of the device (30 or 40 bar), and different lignocaine particle sizes (<38 micrometer or 38-53 micrometer) in a block randomised fashion. RESULTS: A total of 128 patients were evaluable. There was a trend towards improved anaesthesia at higher device pressures at the antecubital fossa with both self reporting and blinded observation. Acceptable analgesia was achieved in 90% of patients for high pressure at both particle sizes compared to 60% and 40% for the sham device using self reporting measures. The observed differences using the blinded observer were similar: 90% v 20% (40 bar and small particles v sham), and 80% v 40% (40 bar and large particles v sham). At the back of hand the differences between active and sham devices were not significant. The device was well tolerated and not associated with pain on deployment. One patient had mild petechiae and oedema after deployment (Draize score of 3). CONCLUSIONS: This prototype device appears to provide significant skin anaesthesia at the antecubital fossa, but not at the back of hand. The device is not painful to use and causes only minor short term skin changes. (+info)
The promise of novel technology for the prevention of intravascular device-related bloodstream infection. I. Pathogenesis and short-term devices.
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Intravascular devices (IVDs) are widely used for vascular access but are associated with substantial risk of development of IVD-related bloodstream infection (BSI). The development of novel technologies, which are based on an understanding of pathogenesis, promises a quantum reduction in IVD-related infections in an era of growing nursing shortages. Infections of short-term IVDs (that is, those in place <10 days), including peripheral venous catheters, noncuffed and nontunneled central venous catheters (CVCs), and arterial catheters, derive mainly from microorganisms colonizing the skin around the insertion site, which most often gain access extraluminally. More-effective cutaneous antiseptics, such as chlorhexidine, a chlorhexidine-impregnated sponge dressing, CVCs with an anti-infective coating, anti-infective CVC hubs, and novel needleless connectors, have all been shown to reduce the risk of IVD-related BSI in prospective randomized trials. The challenge for the future will be to identify new preventative technologies and to begin to adapt more widely those technologies already shown to be efficacious and cost-effective. (+info)
Radial artery cannulation: topical amethocaine gel versus lidocaine infiltration.
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BACKGROUND: In a prospective randomized study, we compared topical 4% amethocaine gel (Ametop) with 2% lidocaine infiltration for analgesia for radial artery cannulation. A previous study had shown topical analgesia with EMLA cream reduced pain, shortened cannulation time, and improved success rates when compared with lidocaine infiltration. METHODS: One hundred adult patients undergoing elective cardiac surgery were randomized. Cannulation times and success rates were compared between the two groups. The quality of analgesia was assessed using a visual analogue scale (VAS) and four-point verbal pain scoring system. RESULTS: Ninety-nine sets of data were analysed using Mann-Whitney U and chi-squared tests. Mean time to cannulation was 56 s in the amethocaine group (interquartile range (IQR) 41-142) and 59 s in the lidocaine group (IQR 40-105). The median pain score on the VAS was 2 in both groups (IQR 1-3.5 for amethocaine and 0-4 for lidocaine). CONCLUSIONS: There was no significant difference between these two methods of analgesia for any measured variable. (+info)