The migrating filter: Inferior vena cava to superior vena cava

A 75-year-old male with past medical history significant for severe chronic obstructive pulmonary disease was admitted to the intensive care unit with respiratory failure. He was found to have an acute deep venous thrombosis (DVT) and pulmonary embolus (PE). A permanent vena cava filter was deployed in the infrarenal inferior vena cava (IVC) at L3 level. A new cavogram confirmed the position of the filter in the inferior vena cava with tip of the filter at the level of the inflow of the left renal vein. Thirty minutes post placement, a routine chest x-ray revealed migration of the filter into the superior vena cava (Figure 1). Unsuccessful attempts were performed to remove the filter through the right internal jugular vein. The patient remained asymptomatic with stable vital signs, no pain or distress. It was elected to leave the migrated inferior vena cava filter in the superior vena cava.The migrating filter: Inferior vena cava to superior vena cava


Perioperative upper airway edema: Risk factors and management

Objectives: To study the risk factors and treatment of the postoperative patient who develops upper airway edema.
Design: Retrospective analysis.
Setting: Surgical Intensive Care Unit (SICU) of a tertiary care hospital.
Patients and participants: We performed a retrospective analysis over 24 months of SICU admissions of postoperative patients. Inclusion criteria were (1) failure to extubate after a surgical procedure, (2) a negative cuff leak test immediately postop (<110 mL of tidal volume loss with the cuff deflated), and (3) failure to extubate within 24 hours with suspected airway edema. Six patients met criteria for study. Interventions: Management of these patients included a multimodal strategy including a daily cuff leak test, use of corticosteroids, diuretics, and head of bed elevation. Measurements and results: All patients were female, with a mean age of 54.5-year-old. The majority had operations remote from the neck region. The mean body mass index (BMI) was 34.8, and the mean surgical time was 282 minutes. Two thirds of the patients were given blood products intraoperatively with a mean of 17.3 units transfused. The mean fluid balance intraoperatively was +5 L. Using our protocol, steroids were administered in the equivalence of 389 mg of hydrocortisone across a mean of 71 hours of mechanical ventilation. Simultaneously, they received a mean of 63 mg of furosemide to achieve a mean fluid balance of -2.8 L. All patients were extubated when the cuff leak became positive; none required reintubation. Conclusion: A multimodal strategy for the patient with postoperative upper airway edema is recommended.


Study of tracheostomized patients in Intensive Care Unit

Objectives: To describe the short-term and long-term outcomes of tracheostomized Intensive Care Unit (ICU) patients and to identify any predictors of complications during and after the tracheostomy procedure.
Design: A retrospective and prospective, observational case series performed in a general medical-surgical adult ICU in a regional hospital in Hong Kong.
Results: A total of 153 patients were recruited. The most common indication for tracheostomy was prolonged mechanical ventilation (72.6%), followed by failure of extubation (15%). Surgical tracheostomy was the predominant method used (73.9%). There were no statistically significant differences between surgical and percutaneous tracheostomy on the complication rate. Minor bleeding was the most common short-term complication (10.5%) and tracheal stenosis was the most common long-term complication (5.1%). Hypertension (adjusted odds ratio 5.28, 95% CI 1.05-26.51, p=0.044) and chronic renal failure (CRF) (adjusted odds ratio 17.56, 95% CI 2.87-107.42, p=0.002) were independent risk factors for minor bleeding; while the need to reintubate within 48 hours after extubation (adjusted odds ratio 10.5, 95% CI 1.30-84.88, p=0.027) was an independent risk factor for tracheal stenosis. CRF was independently associated with composite complications (minor bleeding and tracheal stenosis; adjusted odds ratio 13.63, 95% CI of 2.47-75.16, p=0.003). Mental health score at 1 year or more was generally better than physical health score in this cohort of patients.
Conclusion: This study described the outcome, complications with associated predictors in tracheostomized ICU patients in Chinese population. Further larger trials are required to confirm the findings.


How to initiate noninvasive ventilation program in your hospital

Noninvasive ventilation (NIV) is increasingly being employed in the management of acute respiratory failure associated with a number of disease states. However, while there is strong evidence from randomized trials supporting its routine use in the intensive care units (ICU), the task of integrating NIV into standard practice remains a challenging one. In this article, we discuss different considerations surrounding NIV incorporation into hospitals’ standard programs for managing acute respiratory distress. We also outline the important factors crucial for setting up an NIV program and diffusing its operation and the derivable benefits into a clinic’s respiratory care management system. It is important that the NIV diffusion process is anchored on the experience of a clinical champion, an early adopter and opinion leader who is effective in communicating the benefits of noninvasive mechanical ventilation methods to other clinicians.


Aberrant central venous cannulation of the pericardial vein

Central venous catheter placement is one of the most common procedures in Emergency Departments (ED) and Intensive Care Units (ICU) across the world. A variety of potential complications can occur in patients undergoing these procedures. Incorrect position of the catheter is quite common.Cannulation of azygous arch, occurs in 0.7-1.2% of all central venous catheter insertion, and is seven times more common when access is approached from the left side. (1,2) Due to the venous drainage of the chest wall region, cannulation especially from left side, can lead to the catheters being placed in the aberrant location in hemiazygous vein or one of its tributaries, such as the pericardial veins, as shown in the Figure. The aberrant cannulation of azygous vein or its tributaries carries a high risk for perforation leading to effusions and mediastinal hematomas. (2)Aberrant central venous cannulation of the pericardial vein


Therapeutic hypothermia: Myths and controversies

The use of therapeutic hypothermia (TH) in critical care medicine is no longer a rarity. (1-3) This technique is no longer an urban myth. A variety of robust clinical trials have documented the advantages of using this therapeutic modality in comatose victims of cardiac arrest with successful return of spontaneous circulation (ROSC). (4,5)
TH has many potential applications other than cardiac arrest victims with ROSC and coma. (1,6) Data is available for a variety of critical conditions. Current data clearly indicates that TH protects the cells against the aggressors in hypoxic or anoxic events (not only cardiac-related). (6) TH can protect the microvasculature, reducing the expression of reactive oxygen species; inhibiting adhesion, activation, and accumulation of neutrophils, preserving the adenosine triphosphate storages and maintaining an aerobic metabolism. (1,6)Therapeutic hypothermia: Myths and controversies