BACKGROUND: Simulation-based training (SBT) is vital to complex medical procedures such as ultrasound guided central venous catheterization (US-IJCVC), where the experience level of the physician impacts the likelihood of incurring complications. The Dynamic Haptic Robotic Trainer (DHRT) was developed to train residents in CVC as an improvement over manikin trainers, however, the DHRT and manikin trainer both only provide training on one specific portion of CVC, needle insertion. As such, CVC SBT would benefit from more comprehensive training. An extended version of the DHRT was created, the DHRT + , to provide hands-on training and automated feedback on additional steps of CVC. The DHRT + includes a full CVC medical kit, a false vein channel, and a personalized, reactive interface. When used together, the DHRT and DHRT + systems provide comprehensive training on needle insertion and catheter placement for CVC. This study evaluates the impact of the DHRT + on resident self-efficacy and CVC skill gains as compared to training on the DHRT alone.
METHODS: Forty-seven medical residents completed training on the DHRT and 59 residents received comprehensive training on the DHRT and the DHRT + . Each resident filled out a central line self-efficacy (CLSE) survey before and after undergoing training on the simulators. After simulation training, each resident did one full CVC on a manikin while being observed by an expert rater and graded on a US-IJCVC checklist.
RESULTS: For two items on the US-IJCVC checklist, \"verbalizing consent\" and \"aspirating blood through the catheter\", the DHRT + group performed significantly better than the DHRT only group. Both training groups showed significant improvements in self-efficacy from before to after training. However, type of training received was a significant predictor for CLSE items \"using the proper equipment in the proper order\", and \"securing the catheter with suture and applying dressing\" with the comprehensive training group that received additional training on the DHRT + showing higher post training self-efficacy.
CONCLUSIONS: The integration of comprehensive training into SBT has the potential to improve US-IJCVC education for both learning gains and self-efficacy.

暂无摘要。

Central venous catheterization (CVC) of the internal jugular vein is an invasive procedure commonly performed in anesthesiology practice. Usually it is an uneventful procedure but complications such as bleeding, infection, and potential damage to the surrounding structures can occur. One of the complications is neck hematoma, which can distort airway anatomy and cause upper airway obstruction. We present a patient who underwent endovascular mitral valve repairment procedure under general anesthesia. Accidental puncture of carotid artery occurred while attempting to place the central line. Later, during awakening in the coronary intensive care unit, the patient developed neck hematoma. The diagnosis was confirmed with multi-slice computed tomography (MSCT) and MSCT angiography showed active arterial blood extravasation. Despite it, the patient was extubated. Awake tracheal intubation (ATI) with video laryngoscopy was the technique of choice for reintubation because of the neck swelling and compression onto laryngeal structures. In this case, rushed extubation put the patient at risk. Video laryngoscopy ATI with appropriate preparation and titrated sedation can enable quick and safe rescue airway management in patients with rapidly developing neck hematoma, along with definitive evacuation and treatment.

BACKGROUND: Centrally inserted central catheters (CICCs) are increasingly used in neonatal care. CICCs have garnered attention and adoption owing to their advantageous features. Therefore, achieving clinical competence in ultrasound-guided CICC insertion in term and preterm infants is of paramount importance for neonatologists. A safe clinical training program should include theoretical teaching and clinical practice, simulation and supervised CICC insertions.
METHODS: We planned a training program for neonatologists for ultrasound-guided CICCs placement at our level III neonatal intensive care unit (NICU) in Modena, Italy. In this single-centre prospective observational study, we present the preliminary results of a 12-month training period. Two paediatric anaesthesiologists participated as trainers, and a multidisciplinary team was established for continuing education, consisting of neonatologists, nurses, and anaesthesiologists. We detail the features of our training program and present the modalities of CICC placement in newborns.
RESULTS: The success rate of procedures was 100%. In 80.5% of cases, the insertion was obtained at the first ultrasound-guided venipuncture. No procedure-related complications occurred in neonates (median gestational age 36 weeks, IQR 26-40; median birth weight 1200 g, IQR 622-2930). Three of the six neonatologists (50%) who participated in the clinical training program have achieved good clinical competence. One of them has acquired the necessary skills to in turn supervise other colleagues.
CONCLUSIONS: Our ongoing clinical training program was safe and effective. Conducting the program within the NICU contributes to the implementation of medical and nursing skills of the entire staff.

OBJECTIVE: A standardized ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) using online- and simulation-based training was first designed and then large-scale deployed at a teaching hospital institution to improve CVC surgical education. To understand the impact that the standardized training might have on patient complications, this study focuses on identifying the impact of the integration of an iteratively designed US-IJCVC training on clinical complications at a teaching hospital.
METHODS: A comparative study was conducted using TriNetX, a global health research network. Using Current Procedural Terminology (CPT) codes and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes, we identified the total number of patients with a CVC and mechanical, infectious, and thrombosis complications with and without billable ultrasound between July 1 to June 30 in 2016, 2017, and 2022.
METHODS: A teaching hospital institution in Pennsylvania.
RESULTS: Results showed a correlation between years and complications indicating, (1) mechanical complications billable ultrasound, (2) infectious complications billable ultrasound, and (3) thrombosis complications billable ultrasound were significantly lower with the large-scale deployment. Results also showed that (4) mechanical, infectious, and thrombosis complications with and without billable ultrasound are within the range that prior work has reported.
CONCLUSIONS: These results indicate that there has been a decrease in mechanical, infectious, and thrombosis complications, which correlates with the US-IJCVC training large-scale deployment.

This prospective observational study investigated the optimal insertion depth of the central venous catheter through the right internal jugular vein using transesophageal echocardiography. After tracheal intubation, the anesthesiologist inserted a probe for esophageal echocardiography into the patient\'s esophagus. The investigators placed the catheter tip 2 cm above the superior edge of the crista terminalis with echocardiography, which was defined as the optimal point. We measured the inserted length of the catheter. Pearson correlation tests were performed with the measured optimal depth and some patient parameters. We made a new formula for placing the catheter at the optimal position. A total of 89 subjects were enrolled in this trial. The correlation coefficient between the measured optimal depth and the patient\'s parameters was the highest for patient height (0.703, p < 0.001). We made a new formula of \'height (cm)/10 - 1.5 cm\'. The accuracy rate of this formula for the optimal zone was 71.9% (95% confidence interval; 62.4 - 81.4%), which was the highest among the previous formulas or guidelines when we compared. In conclusion, the central venous catheter tip was evaluated with transesophageal echocardiography, and we could make a new formula of \'height (cm)/10 - 1.5\', which seemed to be better than other previous guidelines.

Centrally inserted central catheters (CICCs) are indispensable in modern healthcare, but unfortunately, come with complications. Catheter-related thrombosis is a well-known complication reported to occur in 5-30% of patients with CICC. There is a paucity of studies that report the incidence of catheter-related thrombosis after the introduction of real-time ultrasound insertion guidance as clinical practice. This study aimed to demonstrate any pathological macro- or microscopic changes in the vein wall associated with CICCs.
The study was approved by the Swedish Ethical Review Authority and was conducted at a large university hospital. The study included 12 patients with a short-term CICC who were subject to autopsies. Vessels with inserted catheters were macroscopically and microscopically examined.
In total, seven female and five male patients with a median age of 70 (interquartile range 63-76) were included. With one exception, all patients received routine thromboprophylaxis throughout the period with CICC. Most inserted CICCs were 9.5 French (54%) and were inserted in the internal jugular vein (92%). The median time with CICC was seven days (interquartile range 1.8-20). At autopsy, thrombi were observed in all cases (100%), macroscopically and microscopically, attached to the distal portion of the CICC and/or the adjacent vessel wall. Inflammatory changes in the vessel walls were seen in all cases, and varying degrees of fibrosis were demonstrated in eight cases (67%).
This autopsy study demonstrated that catheter-related thrombus formation with adjacent inflammatory and fibrotic vessel wall thickening was very common, despite a limited period of catheter use. The consequences of these findings are important, as thrombi may cause pulmonary embolism and possibly lead to catheter-related infections, and since inflammatory and fibrotic vessel wall thickening may evolve into chronic venous stenosis. Furthermore, the findings are a cause of concern, as CICCs are indispensable in modern healthcare and complications may be masked by the general disease that was the indication for CICC insertion.

Fibrin sheath formation is a leading culprit of central venous catheter malfunction. The complete removal of fibrin sheaths is an essential component of maintaining catheter patency, preventing future restenosis, and decreasing the risk of bloodborne infections. Treatment of fibrin sheaths includes pharmacologic therapy, balloon angioplasty, catheter exchange, and mechanical stripping. In this article 3 cases are reviewed, 2 patients had long-term hemodialysis catheter malfunction and 1 had complications related to a chest port. On imaging, superior vena cava stenosis, occlusion, and/or filling defect were identified for all patients, as well as findings suggesting the presence of fibrin sheath. Description of these cases detail a new technique for fibrin sheath removal utilizing the ClotTriever System (Inari Medical, Irvine, CA), which is a mechanical thrombectomy device used for the treatment of deep vein thrombosis. This technique allowed for complete removal of the fibrin sheath via a minimally invasive interventional procedure which did not require access through the central venous catheter lumen.

To determine the tip position of the central venous catheter (CVC) in patients with dialysis, the guidelines recommend that it be determined using chest radiography (CXR) after catheterization, without fluoroscopy. However, some researchers have proposed that transthoracic echocardiography (TTE) can replace CXR, but this has not been widely adopted. This study aimed to determine which of the two aforementioned methods is more suitable for locating the tip position of the CVC. This prospective study included 160 patients who underwent hemodialysis at our hospital from March 2021 to December 2022. After inserting the CVC through the internal jugular vein, we used transthoracic echocardiography and CXR to determine the tip of the CVC and compared the results with those of computed tomography (CT). In the comparison between TTE and CXR for locating the CVC tip, we obtained three main findings. (1) TTE was associated with fewer misdiagnosed cases than CXR. (2) TTE provided higher sensitivity (similar sensitivity in position 2), specificity, positive/negative predictive values, and accuracy than CXR. (3) When comparing the receiver operating characteristic curves of TTE and CXR, the area under the curve (95% confidence interval) for the former was larger. Additionally, we made anatomical discoveries: the \"hyperechoic triangle\" recognized by TTE was equivalent to the entrance of the superior vena cava into the right atrium shown by transesophageal transthoracic echocardiography. TTE is more suitable than CXR as the first examination for CVC tip localization, as it improves diagnostic accuracy and reduces X-ray radiation damage.

Background and Objectives: Tension pneumothorax is a life-threatening emergency condition that requires immediate diagnosis and intervention. However, due to the non-specific symptoms and the rarity of its occurrence during surgery, anesthesiologists encounter difficulties in promptly diagnosing tension pneumothorax when it arises intraoperatively. Diagnosing tension pneumothorax can become even more challenging in unexpected situations in patients with normal preoperative evaluation for general anesthesia. Materials and Methods, Results: We report the case of a 66-year-old woman who underwent general anesthesia for oblique lateral interbody fusion surgery of her lumbar spine. Though she did not have any respiratory symptoms prior to the induction of anesthesia, auscultation following endotracheal intubation indicated decreased breathing sound in the left hemithorax of the chest. Subsequently, her vital signs showed tachycardia, hypotension, and hypoxemia, and the ventilator indicated a gradual increase in the airway pressure. We verified the proper depth of the endotracheal tube to exclude one-lung ventilation, and, in the meantime, learned that there had been unsuccessful attempts at left subclavian venous catheterization by the surgical department on the previous day. Tension pneumothorax was diagnosed through portable chest radiography in the operating room, and needle thoracostomy and chest tube insertion were performed immediately, which in turn stabilized her vital signs and airway pressure. The surgery was uneventful, and the chest tube was removed one week later after evaluation by the cardiothoracic department. The patient was discharged from hospital on postoperative day 14 without known complications. Conclusions: Anesthesiologists should be aware of the conditions and risk factors that may cause tension pneumothorax and remain vigilant for signs of its development throughout surgery, even for patients who show normal preoperative assessments. An undetected small pneumothorax without any symptoms can progress to tension pneumothorax through positive pressure ventilation during general anesthesia, posing a life-threatening situation. If a tension pneumothorax is highly suspected through clinical assessments, its prompt differentiation and timely diagnosis are crucial, allowing for rapid intervention to stabilize vital signs.