Anesthesia: Essays and Researches; 5(2); Jul-Dec 2011 Letters
was treated on the lines of right ventricular failure. Patient developed pulseless electric activity after eight hours of surgery and could not be revived. This was Grade III bone cement implantation syndrome, despite our best efforts we could not revive the patient. So, in conclusion, we should take extra precaution while using bone cement in patients with co-morbid diseases, increase inspired oxygen concentration while using bone cement, and keep a close vigil on the patient’s hemodynamic status during and after use of bone cement to prevent unexpected fatalities; “detect early and act fast” to save the patient.
REFERENCES 1.
Donaldson AJ, Thomson HE, Harper NJ and Kenny NW. Bone cement implantation syndrome. Br J Anaesth 2009;102:18. 2. Govil P, Kakar PN, Arora D, Das S, Gupta N, Govil D, et al. Bone cement implantation syndrome: A report of four cases. Indian J Anaesth 2009;53:214-8. 3. Byrick RJ, Forbes D, Waddell JP. A monitored cardiovascular collapse during cemented total knee replacement. Anesthesiology 1986;65:213-6. 4. British Orthopaedic Associations. Primary total hip replacement: A guide to good practice. 2006. Available from: http://www.boa.ac.uk/site/ showpublications.aspx?ID=59 [Last accessed on 2011 June 30]. 5. Duncan JA. Intra-operative collapse or death related to the use of acrylic cement in hip surgery. Anaesthesia 1989;44:149-53 6. Byrick RJ. Cement implantation syndrome: A time limited embolic phenomenon. Can J Anaesth 1997;44:107-11. Access this article online
Nikhil Mudgalkar, K. V. Ramesh
Department of Anesthesia, Prathima Institute of Medical Sciences, Karimnagar, Andhra Pradesh, India
Website
DOI
www.aeronline.org
10.4103/0259-1162.94796
Quick Response Code
Corresponding author: Dr. Nikhil Mudgalkar, D 101, PIMS Campus, Nugnur, Karimnagar, Andhra Pradesh, India. E-mail: [email protected]
Central venous catheter placement: An alternative of Certodyn® (Universal Adapter) Sir, A use of central venous catheters (CVCs) is increasing day by day. Guidelines for CVCs positioning by FDA and other experts suggest that CVCs tip should not be placed in right atrium in order to avoid complications.[1,2] ECG guided CVCs insertion is done with the help of ECG adapter (Certodyn®, B.Braun Medical). But this adapter is expensive and not easily available in developing countries. Present innovation is an alternative to Certodyn® which is very simple to make and very cost effective to correctly identify CVC tip position during its insertion. Changes in ‘P’ wave amplitude is used as a guide to position CVCs. 1. Two ECG Electrodes [Figure 1a] 2. One ‘U’ shaped steel paper clip [Figure 1c] 3. Certofix® (B.Braun.Medical, Bethlehem, PA) 4. ECG monitor [Figures 2a and b] Two ECG electrodes were stick together by central sticky portion [Figures 1c and 3]. Right Arm lead of ECG monitor was attached to one side of ECG electrode assembly and other leads of ECG monitor were attached to surface electrodes in usual manner. A paper clip was attached to other side on metallic tip of ECG electrode assembly [Figures 1d and 3]. CVC was inserted by usual Seldinger technique. A CVC (20 cm) was inserted over guide wire (50 cm) until 20 cm 242
guide mark of CVC was at skin level. The guide wire was then withdrawn through the catheter until a mark on guide wire indicated the tip to be exactly positioned at the tip of catheter. Then alligator was clip attached to guide
a
b
c
d
Figure 1: (a) Two ECG electrode. (b) One non plastic coated steel ‘U’ paper clip. (c) Adhered two ECG electrode (vertical view). (d) Adhered two ECG electrode with paper clip (horizontal view)
Anesthesia: Essays and Researches; 5(2); Jul-Dec 2011 Letters
secured with skin sutures and dressing was done.
Figure 2a: Showing normal ECG recording on standard monitor
Figure 2b: Showing peaked ‘P’ wave on ECG while putting CVC
It is very important to confirm the correct position of CVCs tip. It should never be placed in right atrium. [1,2] Improper placement of CVCs tip can result into many complications like pleural effusion, hydrothorax, hemothorax, hydromediastinum, pneumothorax, and pneumomediastinum.[3] Radiological method (X-Ray, Image intensifier, computed tomography) are practical and reliable tools for confirmation of depth of CVCs tips. However confirmation by this method is usually done several hours after the insertion of CVCs with extra financial burden on patients or hospital and radiation hazard to patient. Ultrasound have very limited role for aiding confirmation of tip placement. However it is very much useful to find-out correct puncture site. We have developed a very simple and cost effective technique for correct placement of CVCs tip. Principle of our technique is same as that of Certodyn®. Materials used in our technique are easily available and simple to assemble on spot. Its performance is equivalent to Certodyn®. It has no side effects. Safety of patient is ensured and avoids unnecessary exposure to radiation. Hence we conclude that this simple, safe and easy to assemble alternative can be used for accurate positioning of CVCs, thus avoiding complications which are not only difficult to manage but also a financial burden on patient and hospital.
Manish Jain, Bhavana Rastogi, V. P. Singh, Kumkum Gupta
Department of Anaesthesiology and Critical Care, N.S.C.B. Subharti Medical College NH-58, Meerut, India
Corresponding author: Dr. Manish Jain, A-5, Padam Kunj, Kishan Flour Mill, Railway Road, Meerut - 25005, India. E-mail: [email protected]
References 1. 2.
Figure 3: Whole assembly on patient
wire at indicated position. The other end of cable was attached to ‘U’ shaped paper clip [Figure 3]. The catheter with guide wire was slowly adjusted according to ECG guidance. ‘P’ wave on lead II was observed on ECG monitor [Figure 2a]. Peaked ‘P’ wave [Figure 2b] indicates CVCs position in RA (right atrium), then CVC with guide wire was withdrawn until ‘P’ wave return to normal configuration. After further withdrawal of CVC for another 2 cm, CVC was
3.
Scott WL. Central venous catheters: And overview of food and drug administration activities. Surg Oncol Clin N Am 1995;4:377-93. Bowdle TA. Complications of invasive monitoring. Anestheisol Clin North America 2002;20:571-88. Duntley P, Siever J, Korwes ML, Harpel K, Heffner JE. Vascular erosion by central venous catheters. Chest 1993;104:1633-8. Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.94798
Quick Response Code
243
Copyright of Anesthesia: Essays & Researches is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
was treated on the lines of right ventricular failure. Patient developed pulseless electric activity after eight hours of surgery and could not be revived. This was Grade III bone cement implantation syndrome, despite our best efforts we could not revive the patient. So, in conclusion, we should take extra precaution while using bone cement in patients with co-morbid diseases, increase inspired oxygen concentration while using bone cement, and keep a close vigil on the patient’s hemodynamic status during and after use of bone cement to prevent unexpected fatalities; “detect early and act fast” to save the patient.
REFERENCES 1.
Donaldson AJ, Thomson HE, Harper NJ and Kenny NW. Bone cement implantation syndrome. Br J Anaesth 2009;102:18. 2. Govil P, Kakar PN, Arora D, Das S, Gupta N, Govil D, et al. Bone cement implantation syndrome: A report of four cases. Indian J Anaesth 2009;53:214-8. 3. Byrick RJ, Forbes D, Waddell JP. A monitored cardiovascular collapse during cemented total knee replacement. Anesthesiology 1986;65:213-6. 4. British Orthopaedic Associations. Primary total hip replacement: A guide to good practice. 2006. Available from: http://www.boa.ac.uk/site/ showpublications.aspx?ID=59 [Last accessed on 2011 June 30]. 5. Duncan JA. Intra-operative collapse or death related to the use of acrylic cement in hip surgery. Anaesthesia 1989;44:149-53 6. Byrick RJ. Cement implantation syndrome: A time limited embolic phenomenon. Can J Anaesth 1997;44:107-11. Access this article online
Nikhil Mudgalkar, K. V. Ramesh
Department of Anesthesia, Prathima Institute of Medical Sciences, Karimnagar, Andhra Pradesh, India
Website
DOI
www.aeronline.org
10.4103/0259-1162.94796
Quick Response Code
Corresponding author: Dr. Nikhil Mudgalkar, D 101, PIMS Campus, Nugnur, Karimnagar, Andhra Pradesh, India. E-mail: [email protected]
Central venous catheter placement: An alternative of Certodyn® (Universal Adapter) Sir, A use of central venous catheters (CVCs) is increasing day by day. Guidelines for CVCs positioning by FDA and other experts suggest that CVCs tip should not be placed in right atrium in order to avoid complications.[1,2] ECG guided CVCs insertion is done with the help of ECG adapter (Certodyn®, B.Braun Medical). But this adapter is expensive and not easily available in developing countries. Present innovation is an alternative to Certodyn® which is very simple to make and very cost effective to correctly identify CVC tip position during its insertion. Changes in ‘P’ wave amplitude is used as a guide to position CVCs. 1. Two ECG Electrodes [Figure 1a] 2. One ‘U’ shaped steel paper clip [Figure 1c] 3. Certofix® (B.Braun.Medical, Bethlehem, PA) 4. ECG monitor [Figures 2a and b] Two ECG electrodes were stick together by central sticky portion [Figures 1c and 3]. Right Arm lead of ECG monitor was attached to one side of ECG electrode assembly and other leads of ECG monitor were attached to surface electrodes in usual manner. A paper clip was attached to other side on metallic tip of ECG electrode assembly [Figures 1d and 3]. CVC was inserted by usual Seldinger technique. A CVC (20 cm) was inserted over guide wire (50 cm) until 20 cm 242
guide mark of CVC was at skin level. The guide wire was then withdrawn through the catheter until a mark on guide wire indicated the tip to be exactly positioned at the tip of catheter. Then alligator was clip attached to guide
a
b
c
d
Figure 1: (a) Two ECG electrode. (b) One non plastic coated steel ‘U’ paper clip. (c) Adhered two ECG electrode (vertical view). (d) Adhered two ECG electrode with paper clip (horizontal view)
Anesthesia: Essays and Researches; 5(2); Jul-Dec 2011 Letters
secured with skin sutures and dressing was done.
Figure 2a: Showing normal ECG recording on standard monitor
Figure 2b: Showing peaked ‘P’ wave on ECG while putting CVC
It is very important to confirm the correct position of CVCs tip. It should never be placed in right atrium. [1,2] Improper placement of CVCs tip can result into many complications like pleural effusion, hydrothorax, hemothorax, hydromediastinum, pneumothorax, and pneumomediastinum.[3] Radiological method (X-Ray, Image intensifier, computed tomography) are practical and reliable tools for confirmation of depth of CVCs tips. However confirmation by this method is usually done several hours after the insertion of CVCs with extra financial burden on patients or hospital and radiation hazard to patient. Ultrasound have very limited role for aiding confirmation of tip placement. However it is very much useful to find-out correct puncture site. We have developed a very simple and cost effective technique for correct placement of CVCs tip. Principle of our technique is same as that of Certodyn®. Materials used in our technique are easily available and simple to assemble on spot. Its performance is equivalent to Certodyn®. It has no side effects. Safety of patient is ensured and avoids unnecessary exposure to radiation. Hence we conclude that this simple, safe and easy to assemble alternative can be used for accurate positioning of CVCs, thus avoiding complications which are not only difficult to manage but also a financial burden on patient and hospital.
Manish Jain, Bhavana Rastogi, V. P. Singh, Kumkum Gupta
Department of Anaesthesiology and Critical Care, N.S.C.B. Subharti Medical College NH-58, Meerut, India
Corresponding author: Dr. Manish Jain, A-5, Padam Kunj, Kishan Flour Mill, Railway Road, Meerut - 25005, India. E-mail: [email protected]
References 1. 2.
Figure 3: Whole assembly on patient
wire at indicated position. The other end of cable was attached to ‘U’ shaped paper clip [Figure 3]. The catheter with guide wire was slowly adjusted according to ECG guidance. ‘P’ wave on lead II was observed on ECG monitor [Figure 2a]. Peaked ‘P’ wave [Figure 2b] indicates CVCs position in RA (right atrium), then CVC with guide wire was withdrawn until ‘P’ wave return to normal configuration. After further withdrawal of CVC for another 2 cm, CVC was
3.
Scott WL. Central venous catheters: And overview of food and drug administration activities. Surg Oncol Clin N Am 1995;4:377-93. Bowdle TA. Complications of invasive monitoring. Anestheisol Clin North America 2002;20:571-88. Duntley P, Siever J, Korwes ML, Harpel K, Heffner JE. Vascular erosion by central venous catheters. Chest 1993;104:1633-8. Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.94798
Quick Response Code
243
Copyright of Anesthesia: Essays & Researches is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
