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Management of difficult intravenous access: a qualitative review

World Journal of Emergency medicine 2022年第6期13卷 467-478页

作者： Mingwei Ng Leong Kwok Fai Mark Lateef Fatimah department of Emergency medicine Singapore General Hospital

BACKGROUND: A perennial challenge faced by clinicians and made even more relevant with the global obesity epidemic, difficult intravenous access(DIVA) adversely impacts patient outcomes by causing significant downstream delays with many aspects of diagnoses and therapy. As most published DIVA strategies are limited to various point-of-care ultrasound techniques while other “tricks-of-the-trade” and pearls for overcoming DIVA are mostly relegated to informal nonpublished material, this article seeks to provide a narrative qualitative review of the iterature on DIVA and consolidate these strategies into a practical algorithm. METHODS: We conducted a literature search on PubMed using the keywords “difficult intravenous access”, “peripheral vascular access” and “peripheral venous access” and searched emergency medicine and anaesthesiology resources for relevant material. These strategies were then categorized and incorporated into a DIVA algorithm. RESULTS: We propose a Vortex approach to DIVA that is modelled after the Difficult Airway Vortex concept: starting off with standard peripheral intravenous cannulation(PIVC) techniques, progressing sequentially on to ultrasound-guided cannulation and central venous cannulation and finally escalating to the most invasive intraosseous access should the patient be in extremis or should best efforts with the other lifelines fail. CONCLUSION: DIVA is a perennial problem that healthcare providers across various disciplines will be increasingly challenged with. It is crucial to have a systematic stepwise approach such as the DIVA Vortex when managing such patients and have at hand a wide repertoire of techniques to draw upon.

关键词： Difficult intravenous access Venepuncture Vortex Peripheral intravenous cannulation

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Mechanical circulatory support in cardiogenic shock and post-myocardial infarction mechanical complications

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Journal of Geriatric Cardiology 2022年第2期19卷 130-136页

作者： Daniel Rob Jan Bělohlávek nd department of medicine-department of Cardiovascular medicine First Faculty of MedicineCharles University and General University HospitalPragueCzech Republic

Despite advanced therapies,the mortality of patients with myocardial infarction(MI)complicated by cardiogenic shock(CS)remains around 50%.Mechanical complications of MI are rare nowadays but associated with high mortality in patients who present with CS.Different treatment strategies and mechanical circulatory support(MCS)devices have been increasingly used to improve the grim prognosis of refractory CS.This article discusses current evidence regarding the use of MCS in MI complicated by CS,ventricular septal rupture,free wall rupture and acute mitral regurgitation.Device selection should be tailored according to the cause and severity of CS.Early MCS initiation and multidisciplinary team cooperation is mandatory for good results.MCS associated bleeding remains a major complication and an obstacle to better outcomes.Ongoing prospective randomized trials will improve current knowledge regarding MCS indications,timing,and patient selection in the coming years.

关键词： mortality infarction rupture

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A case of persistent refractory hypoglycemia from polysubstance recreational drug use

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World Journal of Emergency medicine 2023年第1期14卷 75-77页

作者： Jie Er Janice Soo Mingwei Ng Terence Kee Liem Chong Boon Kiat Kenneth Tan R Ponampalam department of Emergency medicine Singapore General Hospital169608Singapore

Dear editor,Studies have revealed a significant prevalence of mixed substance abuse,[1-3]and a focused approach towards polysubstance use has been emphasized.[4]Among recreational drugs,cases of hypoglycemia from ecstasy,[5]amphetamine,[6]eutylone,[7]and cannabinoid[8]use have been reported,but none of these cases have had persistent refractory hypoglycemia.

关键词： drugs cases prevalence

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World Journal of Emergency medicine 2022年第5期13卷 422-424页

作者： Ian Zhirui Hong R Ponampalam department of Emergency medicine Singapore General Hospital169608Singapore

Dear editor,Human exposure to hydrocarbons(HCs)is unavoidable given their wide usage in a variety of common products.Ethyl chloride(EC),a type of halogenated HC,has been used in the production of pharmaceuticals,dyes,and other chemicals used for industrial purposes.[1,2]EC was used as an anesthetic induction agent in the early 1900s.[3]Although its use as an inhalational agent has fallen out of favour,EC is still used as a topical pain medication today.[4]

关键词： hydrocarbons agent editor

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Double dartos flap layer in tubularized incised plate urethroplasty to prevent urethrocutaneous fistula in uncircumcised patients with distal hypospadias

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Asian Journal of Andrology 2023年第1期25卷 93-97页

作者： Raed Al-Taher Mohammad Nofal Ali J Yousef Mohammad Rashdan Amjad Tarawneh Jad Alsmadi Eman Hasan Dalal Alshareefi Danah Alenezi Bashayer Abdulrasoul department of general Surgery Division of Pediatric SurgerySchool of MedicineThe University of JordanAmman 11942Jordan department of general Surgery and Anesthesia School of MedicineMutah UniversityKarak 61710Jordan department of Pediatrics School of MedicineMutah UniversityKarak 61710Jordan department of general and Special Surgery Division of UrologyFaculty of MedicineThe Hashemite UniversityZarqa 13133Jordan

Urethrocutaneous fistula may complicate hypospadias repair.We noticed that double-layered preputial dartos flaps added to tubularized incised plate urethroplasty can reduce the risk of urethrocutaneous fistula.The aim of this study was to compare the outcomes of tubularized incised plate urethroplasty with double-layered preputial dartos flaps to with single-layered local fascial flaps in preventing urethrocutaneous fistula.A retrospective cohort study was conducted between January 2017 and December 2020 at Jordan University Hospital(Amman,Jordan).Boys who were aged between 6 months and 5 years,diagnosed with distal hypospadias,and not circumcised were included.The primary outcome was the occurrence of urethrocutaneous fistula in patients who underwent tubularized incised plate urethroplasty with a double-layered fascial flap.The results showed a total of 163 boys with distal hypospadias;among them,116 patients underwent tubularized incised plate urethroplasty with a single-layered fascial flap,and 47 underwent tubularized incised plate urethroplasty with a double-layered fascial flap.The development of urethrocutaneous fistula was higher in the group receiving tubularized incised plate urethroplasty with a single-layered fascial flap than in the group receiving tubularized incised plate urethroplasty with a double-layered fascial flap after 1 month,6 months,and 12 months(6.9%vs 0,10.3%vs 0,and 5.2%vs 0,respectively),and the difference after 6 months was statistically significant(P=0.02).

关键词： distal hypospadias double-layered preputial dartos flap tubularized incised plate urethroplasty urethrocutaneous fistula

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腹部手术患者压力性损伤风险预测模型的开发及验证

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International Journal of Nursing Sciences 2022年第4期9卷 438-444页

作者：冯雪王萌张娅刘倩郭明阳梁鸿寅 department of general Surgery General Hospital of Western Theater Command(Chengdu Military General Hospital)ChengduChina department of Traditional Chinese medicine General Hospital of Western Theater Command(Chengdu Military General Hospital)ChengduChina

目的旨在开发腹部手术患者压力性损伤风险预测诺谟图模型并验证其对预测准确性。方法回顾性收集2017年1月至2020年12月期间在中国西部1所医院普通外科进行腹部外科手术且术后在ICU进行重症监护治疗的11247例患者病历,并从病历中提取患... 详细信息

目的旨在开发腹部手术患者压力性损伤风险预测诺谟图模型并验证其对预测准确性。方法回顾性收集2017年1月至2020年12月期间在中国西部1所医院普通外科进行腹部外科手术且术后在ICU进行重症监护治疗的11247例患者病历,并从病历中提取患者一般资料、术前和术中相关资料、压力性损伤发生情况等。根据手术后患者是否发生压力性损伤对病例进行区分,所有数据根据R软件按8∶2的比例随机分为训练队列(n=8997)及验证队列(n=2250)。对训练队列中的数据采用单因素及多因素logistic回归分析,开发腹部手术患者压力性损伤风险预测诺谟图模型。结果共有873例患者(7.8%)发生了压力性损伤。Logistic回归分析显示,手术时间、体重、手术类型、术前白蛋白、Braden量表评分是压力性损伤发生的独立危险因素,据此构建诺谟图。研究结果显示,该诺谟图用于压力性损伤预测的受试者工作曲线的曲线下面积为0.831,特异性为85.2%,敏感性为63.7%;Braden量表的曲线下面积则为0.567,特异性为33.0%。诺谟图的Hosmer-Lemeshow检验P值为0.45,Braden量表的Hosmer-Lemeshow检验P值为0.22,两者均显示了较好的校准度。在决策曲线分析中,诺谟图也显示了更好的预测效果。结论与Braden评分相比,本研究所构建的诺谟图模型对于腹部手术患者压力性损伤显示出更好的预测效果。尽管这些结果还需要进一步的验证,诺谟图能提供更有效的信息,有潜力为临床护理对于压力性损伤的分级及预防提供帮助。

关键词：成年人列线图病人压力性溃疡外科手术

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Partial improvement in performance of patients with severe Alzheimer's disease at an early stage of fornix deep brain stimulation

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Neural Regeneration Research 2018年第12期13卷 2164-2172页

作者： Zhi-Qi Mao Xin Wang Xin Xu Zhi-Qiang Cui Long-Sheng Pan Xiao-Jing Ning Bai-Xuan Xu Lin Ma Zhi-Pei Ling Jian-Jun Jia Xin-Guang Yu department of Neurosurgery Chinese PLA General Hospital School of medicine Nankai University department of Nuclear medicine Chinese PLA General Hospital department of Radiology Chinese PLA General Hospital department of Neurology Chinese PLA General Hospital

Deep brain stimulation is a therapy for Alzheimer＇s disease（AD） that has previously been used for mainly mild to moderate cases. This study provides the first evidence of early alterations in performance induced by stimulation targeted at the fornix in severe AD patients. The performance of the five cases enrolled in this study was scored with specialized assessments including the Mini-Mental State Examination and Clinical Dementia Rating, both before and at an early stage after deep brain stimulation. The burden of caregivers was also evaluated using the Zarit Caregiver Burden Interview. As a whole, the cognitive performance of patients remained stable or improved to varying degrees, and caregiver burden was decreased. Individually, an improved mental state or social performance was observed in three patients, and one of these three patients showed remarkable improvement in long-term memory. The conditions of another patient deteriorated because of inappropriate antipsychotic medications that were administered by his caregivers. Taken together, deep brain stimulation was capable of improving some cognitive aspects in patients with severe AD, and of ameliorating their emotional and social performance, at least at an early stage. However, long-term effects induced by deep brain stimulation in patients with severe AD need to be further validated. More research should focus on clarifying the mechanism of deep brain stimulation. This study was registered with ClinicalTrials.gov（NCT03115814） on April 14, 2017.

关键词： Alzheimer＇s disease deep brain stimulation fornix cognition memory mood performance early stage functional neurosurgery dementia

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Clinical differentiation of acute appendicitis and right colonic diverticulitis: A case-control study

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World Journal of Clinical Cases 2019年第12期7卷 1393-1402页

作者： Yosuke Sasaki Fumiya Komatsu Naoyasu Kashima Takahiro Sato Ikutaka Takemoto Sho Kijima Tadashi Maeda Takamasa Ishii Taito Miyazaki Yoshiko Honda Nagato Shimada Yoshihisa Urita Department of General Medicine and Emergency Care Toho University School of Medicine

BACKGROUND Acute right colonic diverticulitis (ARCD) is an important differential diagnosis of acute appendicitis (AA) in Asian countries because of the unusually high prevalence of right colonic diverticula. Due to qualitative improvement and the high penetration rate of computed tomography (CT) scanning in Japan, differentiation of ARCD and AA mainly depends on this modality. But cost, limited availability, and concern for radiation exposure make CT scanning problematic. Differential findings of ARCD from AA are based on several small studies that used univariate comparisons from Korea and Taiwan. Previous studies on clinical and laboratory differences between AA and ARCD are limited. AIM To determine clinical differences between AA and ARCD for differentiation of these two diagnoses by creating a logistic regression model. METHODS We performed an exploratory single-center retrospective case-control study evaluating 369 Japanese patients (age ≥ 16 years), 236 (64.0%) with AA and 133 (36.0%) with ARCD, who were hospitalized between 2012 and 2016. Diagnoses were confirmed by CT images. We compared age, sex, onset-to-visit interval, epigastric/periumbilical pain, right lower quadrant (RLQ) pain, nausea/vomiting, diarrhea, anorexia, medical history, body temperature, blood pressure, heart rate, RLQ tenderness, peritoneal signs, leukocyte count, and levels of serum creatinine, serum C-reactive protein (CRP), and serum alanine aminotrans-ferase. We subsequently performed logistic regression analysis for differentiating AA from ARCD based on the results of the univariate analyses.RESULTS In the AA and ARCD groups, median ages were 35.5 and 41.0 years, respectively (p=0.011);median onset-to-visit intervals were 1 [interquartile range (IQR): 0-1] and 2 (IQR: 1-3) days, respectively (P < 0.001);median leukocyte counts were 12600 and 11500/mm3, respectively (P = 0.002);and median CRP levels were 1.1 (IQR: 0.2-4.1) and 4.9 (IQR: 2.9-8.5) mg/dL, respectively (P < 0.001). In the logistic regression model, odds ratios (ORs) w

关键词： Abdominal pain Acute abdomen Appendicitis Clinical difference Creactive protein Diverticulitis Right lower quadrant pain

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Light chain cardiac amyloidosis in a nonagenarian

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Journal of Geriatric Cardiology 2022年第1期19卷 83-89页

作者： Koji Takahashi Mina Yamashita Tomoki Sakaue Daijiro Enomoto Shigeki Uemura Takafumi Okura Shuntaro Ikeda Takanori Senba Akira Saijo Nobuhisa Yamamura Sohei Kitazawa department of Community Emergency medicine Ehime University Graduate School of MedicineEhimeJapan department of Cardiology Yawatahama City General HospitalEhimeJapan department of Hematology Yawatahama City General HospitalEhimeJapan department of Clinical Pathology Yawatahama City General HospitalEhimeJapan department of Molecular Pathology Ehime University Graduate School of MedicineEhimeJapan

Cardiac amyloidosis is an infiltrative and restrictive cardiomyopathy caused by the extracellular deposition of amyloid fib-rils within the heart as systemic amyloidosis,lead-ing to heart failure,reduced quality of life,and death.[1]There are two major amyloid fibril proteins that af-fect the heart:amyloid immunoglobulin light chain(AL)and amyloid transthyretin(ATTR).The latter is further subdivided into wild-type ATTR and variant types based on the presence of a mutation in the transthyretin gene.

关键词： amyloid death. cardiomyopathy

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Abnormal liver function tests associated with severe rhabdomyolysis

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World Journal of Gastroenterology 2020年第10期26卷 1020-1028页

作者： Andy KH Lim Department of General Medicine Monash Health department of medicine School of Clinical Sciences Monash University

Rhabdomyolysis is a syndrome of skeletal muscle injury with release of cellular constituents such as potassium,phosphate,urate and intracellular proteins such as myoglobin into the circulation,which may cause complications including acute kidney injury,electrolyte disturbance and cardiac instability.Abnormal liver function tests are frequently observed in cases of severe rhabdomyolysis.Typically,there is an increase in serum aminotransferases,namely aspartate aminotransferase and alanine aminotransferase.This raises the question of liver injury and often triggers a pathway of investigation which may lead to a liver biopsy.However,muscle can also be a source of the increased aminotransferase activity.This review discusses the dilemma of finding abnormal liver function tests in the setting of muscle injury and the potential implications of such an association.It delves into some of the clinical and experimental evidence for correlating muscle injury to raised aminotransferases,and discusses pathophysiological mechanisms such as oxidative stress which may cause actual liver injury.Serum aminotransferases lack tissue specificity to allow clinicians to distinguish primary liver injury from muscle injury.This review also explores potential approaches to improve the accuracy of our diagnostic tools,so that excessive or unnecessary liver investigations can be avoided.

关键词： Rhabdomyolysis Muscle Creatine kinase Liver function tests Alanine aminotransferase Aspartate aminotransferase Aminotransferases

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