Frequent malpositions of peripherally inserted central venous catheters in patients undergoing head and neck surgery
Leonid Minkovich
0
1
George Djaiani
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1
Stuart A. McCluskey
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1
Nicholas Mitsakakis
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1
MSc
0
1
Ralph W. Gilbert
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1
MB
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1
W. Scott Beattie
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1
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R. W. Gilbert,
MB Department of Otolaryngology, Head and Neck Surgery, Toronto General Hospital, University Health Network, University of Toronto
,
Toronto, ON, Canada
1
L. Minkovich,
MD
, PhD (&) G. Djaiani, MD S. A. McCluskey,
MD
, PhD N. Mitsakakis, MSc W. S. Beattie,
MD
,
PhD Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network, University of Toronto
, 3 Eaton North Wing-410, 200 Elizabeth Street,
Toronto
, ON M5G 2C4,
Canada
Purpose Peripherally inserted central venous catheters (PICCs) do not interfere with surgical access during neck dissection and are used in patients undergoing head and neck surgery. However, severe complications associated with malpositioning of PICCs have been reported in these patients. We conducted a retrospective study to determine the incidence of aberrant positioning of PICCs in patients undergoing free flap reconstructive (FFR) surgery for head and neck malignancies. Methods We analyzed a database of 269 patients undergoing FFR surgery. After induction of general anesthesia, a PICC was inserted successfully in 130 patients (48%) at bedside without image guidance. A PICC was not used in 139 patients (52%). A chest x-ray was performed at admission to the postanesthetic care unit, stored digitally, and reviewed retrospectively by two independent observers. Based on the chest x-ray findings, the PICC position was classified as proper, suboptimal, or aberrant and defined according to the position of the PICC tip, i.e., proper, if situated in the ipsilateral innominate
-
vein or in the superior vena cava; suboptimal, if situated in
the subclavian vein; and aberrant, if situated in any other
location.
Results Proper, suboptimal, and aberrant PICC
positions were found in 68 (52%), 17 (13%), and 45 (35%)
patients, respectively. The proper position was confirmed
more frequently with a left- than with a right-sided
approach: 23/29 (79%) vs 45/101 (44%) patients,
respectively (P \ 0.001).
Conclusions There is a high incidence of aberrant
positioning when PICCs are inserted without image
guidance. The left-sided approach might be preferable due to a
lower incidence of malpositions. The risk-benefit ratio
should be estimated carefully before using a PICC in
patients undergoing FFR procedures.
Resume
Objectif Les catheters veineux centraux inseres par voie
peripherique (PICC) ninterfe`rent pas avec lacce`s
chirurgical pendant la dissection du cou et sont utilises
chez les patients subissant des chirurgies au niveau de la
tete et du cou. Toutefois, de graves complications associees
au mauvais positionnement des PICC ont ete rapportees
chez ces patients. Nous avons realise une etude
retrospective afin de determiner lincidence de
positionnement aberrant des PICC chez les patients
subissant une chirurgie de reconstruction par lambeau
libre (RLL) pour des tumeurs malignes a` la tete et au cou.
Methode Nous avons analyse une base de donnees de
269 patients subissant une chirurgie par RLL.
Apre`s linduction de lanesthesie generale, un PICC a ete
insere avec succe`s chez 130 patients (48 %) au chevet sans
echoguidage. Un PICC na pas ete utilise chez 139 patients
(52 %). Une radiographie des poumons a ete realisee lors
de ladmission en salle de reveil, enregistree sous forme
numerique et passee en revue retrospectivement par deux
observateurs independants. Selon les resultats de la
radiographie pulmonaire, le positionnement du PICC etait
classe comme etant correct, sous-optimal ou aberrant, et
defini selon lemplacement du bout du PICC, cest-a`-dire
correct si situe dans la veine innominee ipsilaterale ou
dans la veine cave superieure; sous-optimal si situe dans la
veine sous-clavie`re; et aberrant si situe a` tout autre
emplacement.
Resultats Des positionnements corrects, sous-optimaux
et aberrants du PICC ont ete observes chez 68 (52 %), 17
(13 %), et 45 (35 %) patients, respectivement. Un
positionnement correct a ete confirme plus frequemment
lors dune approche par la gauche que par la droite :
23/29 (79 %) vs 45/101 (44 %) patients, respectivement
(P \ 0,001).
Conclusion Il existe une incidence elevee de positionnement
aberrant lorsque les PICC sont inseres sans echoguidage.
Lapproche par la gauche pourrait etre preferable en raison
dune incidence moindre de mauvais positionnements. Il
convient de bien evaluer les risques et les avantages avant
davoir recours a` un PICC chez les patients subissant des
interventions de RLL.
Viability of the free tissue flap depends on adequate
perfusion of the vascular pedicle after performing
microsurgical free flap reconstruction (FFR) in head and neck
surgery.1 Despite well-known limitations,2 central venous
pressure (CVP) measurement is still used in many
institutions to monitor perioperative fluid therapy. In
reconstructive surgery for head and neck malig (...truncated)