Minimising risks of suprapubic catheter insertion

The UK National Health Service’s National Patient Safety Agency published a report entitled Minimising risks of suprapubic catheter insertion ‘, reporting three incidents of death and seven causing severe harm from suprapubic catheter placement between September 2005 and June 2009, nine of which involved bowel perforation. There were also 249 other incidents reported relating to suprapubic catheters causing lesser degrees of harm. They issue the following recommendations under the title ‘For IMMEDIATE ACTION by medical directors in acute and community hospitals (NHS and Independent Sector). Deadline for ACTION COMPLETE is 29 April 2010’:

  • Information about the risk of this procedure is immediately distributed to all staff who may insert or request the insertion of a suprapubic catheter.
  • A named lead for training is identified and a training plan developed.
  • Local guidelines/policies are reviewed or developed in the light of this report and forthcoming British Association of Urological Surgeons (BAUS) standards.
  • Ultrasound is used wherever possible to visualise the bladder and guide the insertion of the catheter. There should be ultrasound machines available in the relevant areas and staff trained in their use.
  • Local incident data relating to suprapubic catheterisation is reviewed, appropriate action is taken and staff are encouraged to report further incidents and to take part in the BAUS national clinical audit.

Minimising risks of suprapubic catheter insertion
National Patient Safety Agency

Insertion of chest drains

The UK National Health Service’s National Patient Safety Agency published a report entitled ‘Risks of chest drain insertion’, reporting 12 deaths and 15 cases of serious harm related to chest drain insertion over a three year period. They issue the following recommendations under the title ‘For IMMEDIATE ACTION by the NHS and independent sector – Deadline for ACTION COMPLETE is 17 November 2008’:
Clinical governance leads in local organisations should audit current practice and develop local policies to ensure:

  • Chest drains are only inserted by staff with relevant competencies and adequate supervision
  • Ultrasound guidance is strongly advised when inserting a drain for fluid
  • Clinical guidelines are followed and staff made aware of the risks
  • Identify a lead for training of all staff involved in chest drain insertion
  • Written evidence of consent is obtained from patients before the procedure, wherever possible
  • Local incident data relating to chest drains is reviewed and staff encouraged to report further incidents

Chest drains: risks associated with the insertion of chest drains
National Patient Safety Agency

Therapeutic hypothermia for newborns

In three randomised controlled trials encompassing 767 infants with hypoxic-ischaemic encephalopathy, induced moderate hypothermia for 72 hours significantly reduced the combined rate of death and severe disability, with a number needed to treat of nine (95% CI 5 to 25). Hypothermia increased survival with normal neurological function, with a number needed to treat of eight (95% CI 5 to 17), and in survivors reduced the rates of severe disability and cerebral palsy. The studies used different cooling methods and different target temperatures (33-34 deg C vs 34-35 deg C), suggesting the method of cooling itself is not important as long as therapeutic hypothermia is achieved.
Neurological outcomes at 18 months of age after moderate hypothermia for perinatal hypoxic ischaemic encephalopathy: synthesis and meta-analysis of trial data
BMJ. 2010 Feb 9;340:c363

Supraclavicular approach to subclavian vein

A series of subclavian vein catheterisations is described in patients using the supraclavicular approach, with a high success rate and few complications. 290 of the 370 patients were mechanically ventilated at the time of the procedure
How they did it:

  • The point of needle insertion was identified 1 cm cephalad and 1 cm lateral to the junction of the lateral margin of the clavicular head of the sternocleidomastoid muscle with the superior margin of the clavicle (claviculosternocleidomastoid angle)
  • The direction of the needle was indicated by the line that bisects the claviculosternocleidomastoid angle with elevation 5–15 degrees above the coronal plane.
  • The needle was advanced slowly with a constant negative pressure in the syringe.
  • The vein was usually punctured between the clavicle and the attachment of the anterior scalene muscle to the first rib.
  • The subclavian artery is situated posterior and slightly superior to the vein; if palpable, the pulse of the artery could be the important landmark
  • The depth of catheter insertion was 14 cm for right side and 18 cm for left side catheterization.

Supraclavicular approach is an easy and safe method of subclavian vein catheterization even in mechanically ventilated patients: analysis of 370 attempts
Anesthesiology. 2009 Aug;111(2):334-9
EMRAP.TV has a video on supraclavicular central line insertion here

Open Fractures of the Lower Limb

Two major British surgical associations, the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the British Orthopaedic Association (BOA) have worked together to create updated multi-disciplinary standards for the treatment of open fractures of the lower limb

The recommendations are summarised as:
Standards for Practice Audit:
1. Intravenous antibiotics are administered as soon as possible, ideally within 3 hours of injury: Co-amoxiclav (1.2g) or Cefuroxime (1.5g) 8 hourly and are continued until wound debridement. Clindamycin 600mg, 6 hourly if penicillin allergy
2. The vascular and neurological status of the limb is assessed systematically and repeated at intervals, particularly after reduction of fractures or the application of splints
3. Vascular impairment requires immediate surgery and restoration of the circulation using shunts, ideally within 3-4 hours, with a maximum acceptable delay of 6 hours of warm ischaemia
4. Compartment syndrome also requires immediate surgery, with 4 compartment decompression via 2 incisions
5. Urgent surgery is also needed in some multiply injured patients with open fractures or if the wound is heavily contaminated by marine, agricultural or sewage matter.
6. A combined plan for the management of both the soft tissues and bone is formulated by the plastic and orthopaedic surgical teams and clearly documented
7. The wound is handled only to remove gross contamination and to allow photography, then covered in saline-soaked gauze and an impermeable film to prevent desiccation
8. The limb, including the knee and ankle, is splinted
9. Centres that cannot provide combined plastic and orthopaedic surgical care for severe open tibial fractures have protocols in place for the early transfer of the patient to an appropriate specialist centre
10. The primary surgical treatment (wound excision and fracture stabilisation) of severe open tibial fractures only takes place in a non-specialist centre if the patient cannot be transferred safely
11. The wound, soft tissue and bone excision (debridement) is performed by senior plastic and orthopaedic surgeons working together on scheduled trauma operating lists within normal working hours and within 24 hours of the injury unless there is marine, agricultural or sewage contamination. The 6 hour rule does not apply for solitary open fractures. Co-amoxiclav (1.2g) and Gentamicin (1.5mg/kg) are administered at wound excision and continued for 72 hours or definitive wound closure, which ever is sooner
12. If definitive skeletal and soft tissue reconstruction is not to be undertaken in a single stage, then vacuum foam dressing or an antibiotic bead pouch is applied until definitive surgery.
13. Definitive skeletal stabilisation and wound cover are achieved within 72hours and should not exceed 7 days.
14. Vacuum foam dressings are not used for definitive wound management in open fractures.
15. The wound in open tibial fractures in children is treated in the same way as adults
The full guidelines are available here

Securing infant tracheal tubes

Small head movements can cause significant tracheal tube migration in infants unless the tube is adequately secured.
Many use a version of the Melbourne strapping method:
1. Equipment required: Silk suture (cut off needle), ‘Cavilon’, elastoplast cut into 3 strips – 2 trouser shaped, and one with a 4cm hole in middle.

2. Apply Cavilon to face (a barrier film to protect the skin) over the area shown by red blobs in the picture.

3. Tie the suture around the tracheal tube. This marks the tube position at the mouth, and allows the tube to be held in place during fixation and when the tapes are later changed.

Pull the two ends taut across both cheeks.
3. While the suture is being pulled taut, place the first ‘trousers’ so that the undivided end is along the cheek (over the tape). The lower ‘leg’ is placed between the lower lip and the chin.

The upper ‘leg’ is folded back on itself to make it easier to removed at a later stage. It is then wound around the tracheal tube

4. The second set of ‘trousers’ is then applied on the other side, once again with the undivided end over the cheek and suture.

The upper ‘leg’ goes between the nose and the top lip and the lower leg is wound around the tracheal tube.

5. Finally the third piece of elastoplast is placed so that the tube goes through the hole

and applied over the other tapes. If there is an orogastric tube this should also go through the hole. The tube is now secure for transfer.

Thrombophilia screening

A young patient presents with pulmonary embolism. Should you send blood to the lab for a thrombophilia screen? What if she is pregnant? How about a patient with an upper limb DVT, or a child with a stroke?

The answers, in order, are: not necessarily; possibly – trials are ongoing; it depends; and ‘not indicated’. At least according to the The British Committee for Standards in Haematology (BCSH) in their 2009 document ‘Clinical guidelines for testing for heritable thrombophilia’
The document highlights the lack of evidence that the results of thrombophilia screening influence type or duration of management, or predict likelihood of recurrence in unselected patients with symptomatic venous thrombosis. Furthermore, the results of thrombophilia tests are frequently misinterpreted. Many more situations and conditions are covered in the full document.
‘Clinical guidelines for testing for heritable thrombophilia’
Other The British Committee for Standards in Haematology guidelines

Pre-hospital thoracotomy and aortic clamping in blunt trauma

This is one of those ‘wow they really do that!?‘ papers…Patients undergoing thoracotomy and aortic clamping for pre-hospital blunt traumatic arrest either in the field or in the ED were evaluated for the outcome of survival to ICU admission. None of the 81 patients who underwent this intervention survived to discharge.
Field thoracotomy resulted in shorter times from arrival of the emergency medical team to performance of the thoracotomy (19.2 vs 30.7 mins). Patients who arrested in front of the team had a greater ICU admission rate than those who were already in cardiac arrest when the team arrived (70% vs 8%).
One may argue against an intervention that seems to have resulted in no benefit to the patient. However a counterargument might be that an ICU admission allows for better end-of-life management for grieving families, and for the possibility of organ donation.
Interestingly, there were some neurologically intact survivors of emergency thoracotomy for blunt trauma by this service, although they were excluded from the study for either (i) receiving the field thoracotomy before full arrest or (ii) arresting after arrival in the ED.
Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system
Resuscitation. 2009 Nov;80(11):1270-4

Some causes of a raised lactate

A high serum lactate does not necessarily mean a bad prognosis: it all depends on the cause.
I made this diagram as a mnemonic for the causes of high lactates:

Additional information added 1st June 2011
: One cause of an elevated lactate may be artefactual, secondary to interference with the assay (used on ABG machines) by ethylene glycol. The assay may also be subject to interference from certain drugs at toxic levels such as isoniazid, acetaminophen and thiocyanate. This information is from the Renal Fellow Network.