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PubMed1990

Impaired epidural analgesia after dural puncture with and without subsequent blood patch.

We carried out a retrospective assessment of epidural analgesia in 46 parturients who had a previous dural puncture. Of 29 women who had both dural puncture and blood patch previously, only 59% had an uncomplicated successful second epidural anesthetic. Of 17 parturients who had dural puncture but no blood patch previously, only 65% had an uncomplicated successful subsequent epidural anesthetic. In comparable groups of parturients without previous dural puncture, 88%-92% had successful epidural analgesia. The data suggest that dural puncture may lead to impaired epidural analgesia subsequently. Epidural blood patch after dural puncture did not lead to any further decrease in the rate of good analgesia with subsequent epidural anesthetics. Parturients who request epidural analgesia and who have had previous dural puncture with or without blood patch should be informed about the 35%-40% chance of poor epidural analgesia.

Adult↗
PubMed1991

Endocrine stress response in rats subjected to singular orbital puncture while under diethyl-ether anaesthesia.

In an attempt to assess possible discomfort in rats subjected to orbital puncture while under diethyl-ether anaesthesia, their endocrine stress response was determined. Concentrations of corticosterone, adrenaline and noradrenaline were measured in plasma obtained via a jugular catheter from rats subjected to diethyl-ether anaesthesia with or without orbital puncture. No statistically significant differences were found between the punctured and non-punctured rats as to peak levels of plasma corticosterone and adrenaline as well as for the times required by the increased concentrations to return to baseline values. The rate by which the plasma noradrenaline level returned to baseline values was somewhat decreased by orbital puncture. Diethyl-ether anaesthesia alone produced a marked endocrine response when compared with handling and novelty stress associated with the induction of anaesthesia. It is concluded that diethyl-ether anaesthesia causes pronounced increases in the plasma levels of the selected stress hormones and that orbital puncture does not amplify this response. It is suggested that diethyl-ether anaesthesia masks any effects of orbital puncture.

Animals↗
PubMed1984

Guidelines for cervical myelography: lumbar versus cervical puncture technique.

Cervical myelography may be performed with non-ionic contrast media either by direct cervical puncture or by lumbar puncture with run-up of the contrast medium. In this prospective study of 300 cervical myelograms using iopamidol (130 by direct puncture and 170 by lumbar puncture), we have shown that the run-up technique causes no more side effects than direct puncture technique and films of equivalent diagnostic quality are obtained. A sub-group of 80 patients had EEG examinations before and after myelography, plus a lateral skull film taken at the end of the myelogram to assess the amount of contrast medium that had entered the skull. More EEG abnormalities were found in those patients examined by direct puncture and significantly more contrast medium had entered the skull in this group. Run-up myelography therefore results in less intracranial spill and so less potential for cortical irritation. In view of the EEG abnormalities, anticonvulsant premedication is discussed, and we now give phenytoin to all patients having cervical myelography with iopamidol. We consider that cervical myelography can be adequately and more safely performed by lumbar puncture technique but, to optimise patient safety, should be performed by a radiologist experienced in neuroradiology.

Anticonvulsants↗
PubMed2003

Accuracy of pleural puncture sites: a prospective comparison of clinical examination with ultrasound.

STUDY OBJECTIVE: To assess the value of chest ultrasonography vs clinical examination for planning of diagnostic pleurocentesis (DPC). DESIGN: Prospective comparative study. SETTING: Pulmonary unit of a tertiary teaching hospital. PATIENTS AND PARTICIPANTS: Sixty-seven consecutive patients referred to 30 physicians of varying degrees of experience for DPC. INTERVENTIONS: Based on clinical data and examination, physicians determined whether and where a DPC should be performed. Selected puncture sites were evaluated with ultrasound and considered accurate when > or = 10 mm fluid perpendicular to the skin were present. MEASUREMENTS AND RESULTS: In 172 of 255 cases (67%), a puncture site was proposed. Twenty-five sites (15%) were found to be inaccurate on ultrasound examination, and a different, accurate site was established in 20 of these cases. Physicians were unable to locate a puncture site in 83 cases (33%). Among these, ultrasound demonstrated an accurate site in 45 cases (54%), while a safe tap was truly impossible in 38 cases (46%). Overall, ultrasound prevented possible accidental organ puncture in 10% of all cases and increased the rate of accurate sites by 26%. The sensitivity and specificity for identifying a proper puncture site with clinical examination compared to ultrasound as the "gold standard" were 76.6% and 60.3% (positive and negative predictive values, 85.5% and 45.8%, respectively). Risk factors associated with inaccurate clinical site selection were as follows: small effusion (p < 0.001), evidence of fluid loculation on chest radiography (p = 0.01; relative risk, 7.8; 95% confidence interval, 1.9 to 32.9), and sharp costodiaphragmatic angle on chest radiography (p < 0.001; relative risk, 7.0; 95% confidence interval, 2.3 to 15.2). Experienced physicians did not perform better than physicians in training. CONCLUSIONS: Puncture site selection with bedside ultrasonography increases the yield of and potentially reduces complication rate in DPC. Physician experience does not predict the accuracy of selected puncture sites.

Adult↗
PubMed1986

Neurological deterioration after lumbar puncture below complete spinal subarachnoid block.

The risk of neurological deterioration after removal of cerebrospinal fluid below the level of a complete spinal subarachnoid block is generally accepted. The actual incidence of deterioration after lumbar puncture in the presence of a complete block remains unknown. The present retrospective case analysis includes a review of 100 patients found to have complete block on myelography: 50 cases with a lumbar puncture and 50 cases with a C1-2 puncture. Each group consisted of a similar age range, neurological status prior to myelography, level of block, and nature of disease. Seven patients (14%) had significant neurological deterioration after lumbar puncture, while no deterioration was seen after a C1-2 puncture. A summary of those cases in which deterioration followed lumbar puncture is presented and the possible pathophysiology is discussed. From this analysis, the estimated risk of downward spinal coning after lumbar puncture below a complete spinal subarachnoid block caused by a mass lesion is at least 14%.

Abscess↗
PubMed1999

Influence of repetitive finger puncturing on skin perfusion and capillary blood analysis in patients with diabetes mellitus.

BACKGROUND: Frequent puncturing of fingers to check blood glucose in patients with type 1 diabetes might alter skin perfusion and, hence, influence the representativeness of the blood sample. We investigated the influence of repetitive puncturing on skin microcirculatory perfusion using laser Doppler fluxmetry and on the preanalytical phase of capillary blood analysis for small molecules (glucose) and large particles (cholesterol). METHODS: In 49 patients with long-standing (mean, 21 years) type 1 diabetes, with a mean puncture frequency of three times daily for a mean duration of 13 years, laser Doppler skin perfusion was measured in a finger at a frequently punctured site and compared with a similar site of another finger of the same hand, which was never punctured. In the supine position with the hand level with the heart, resting flux (RF), peak flux (PF), and the microcirculatory reserve capacity (MRC; PF - RF) were assessed. Subsequently, blood samples for capillary whole blood glucose and cholesterol analyses were taken from the same sites. RESULTS: No significant differences were found between the puncture and control sites in mean RF (2.3 vs 2.0 V; P = 0.14, paired-samples t-test), PF (3.3 vs 3.1 V; P = 0.24), MRC (1.0 vs 1.0 V; P = 0.65), glucose (10.2 vs 10.2 mmol/L; P = 0.69), or cholesterol (5.1 vs 5.2 mmol/L; P = 0.26). Power calculation for a RF of 2.0 V and the SD and n of this study indicate a power (beta) of 80% to detect a 25% change in RF at P <0.05. CONCLUSIONS: Repetitive finger puncturing in diabetics appears not to injure local skin microcirculatory perfusion nor to influence results of capillary blood analysis for glucose and cholesterol.

Adult↗
PubMed1992

[Echocardiography-guided transseptal left atrial puncture: a safe approach to percutaneous transvenous mitral commissurotomy].

Transseptal left atrial puncture has generally been carried out under fluoroscopic control. In our experience, cardiac tamponade occurred in 3 of 83 cases during transseptal puncture for percutaneous transvenous mitral commissurotomy (PTMC) and percutaneous transvenous aortic valvuloplasty (PTAV). We tried to perform the puncture under simultaneous fluoroscopic and 2DE guidance to decrease the rate of complications. As a result, no complication has occurred in 55 cases. Furthermore, 2DE indicated that directing the puncture needle towards 4 or 5 o'clock was inappropriate, but that 3 o'clock was an appropriate direction for puncture of the fossa ovalis of a left atrium dilated because of mitral stenosis. In conclusion, transseptal left atrial puncture can safely and easily be carried out under a combination of fluoroscopic and 2DE guidance, as this procedure displays the correct position and direction of the needle tip for interatrial septal puncture.

Adolescent↗
PubMed1989

[Serious complications of sternal puncture].

Fatal complications of sternal puncture are, as a rule, the result of penetration of the needle through the sternum followed by lesion of the pericardium and myocardium and finally pericardial tamponade and death. Thirty-four such cases are studied with a view to the technique and especially the site on the sternum where the puncture was made. It was supposed that the punctures in the sternum in the fatal cases were performed below the level of the second intercostal space and that that was the primary cause of the fatal outcome as the heart and pericardium here are very close to the sternum. Punctures at the level of the second intercostal space and higher should be reasonably safe. To the astonishment of the author, it was found that many of the fatal punctures were made in the sternum at the level of the second intercostal space or higher. The many reports in the literature were examined again and it was concluded that the complications might be due to inexperience and lack of training of the person who performed the puncture. It is concluded that puncture of the iliac crest with marrow aspiration and biopsy is preferable for better diagnostic value and a safer procedure.

Cardiac Tamponade↗
PubMed1986

[Meningitis following lumbar puncture in bacteremia?].

We report on two infants with bacteremia and the clinical signs of meningitis who developed overt meningitis following an extended period after the first lumbar puncture, in which inconspicuous (cytological and bacteriological) cerebrospinal fluid were found. The causative infective agents of bacteremia and meningitis were identical. The iatrogenic induction of meningitis by the procedure of lumbar puncture in the presence of a bacteremia is imaginable, but has not been proven. Diagnostic consequences are: Every lumbar puncture for bacterial meningitis has to be complemented with a simultaneous blood culture. Lumbar puncture should be repeated when clinical signs of meningitis persists in children, especially in infants with positive blood culture and with inconspicuous cerebrospinal fluid findings in the initial lumbar puncture. Such children should be hospitalized for clinical observation. Therapeutical consequences are presently unclear. Proven recommendations are lacking for the different possible procedures after initial lumbar puncture in children with suspicion of a bacteremia: for instance no therapy or one single antibiotic dose given i.v. immediately following the lumbar puncture or the same treatment as in proven meningitis until microbiological results are obtained.

Humans↗
PubMed1994

[Continuous guidance for venous punctures using a new pulsed Doppler probe: efficiency, safety].

Serious complications may occur after "blind" profound venous puncture in intensive care units. To secure these punctures, we designed a new fingertip pulsed Doppler (FPD) 5 MHz probe with a lateral to center indentation to guide the needle into the ultrasonic flux. A specific ultrasound analyzer indicating depth and diameter of the vessel was made for this use. The material was first tested in an experimental animal study. Results of animal venous punctures were successful 20/21. This material was then tested on patients with previous failure of "blind" punctures: results of 4 FPD punctures were successful in all 12 cases but one (catheterization not completed). We started a prospective multi-unit randomized study with various operators (junior residents, senior staff members), compared the success rate and type, the procedure duration of blind standard versus FPD punctures. We conclude in the safety and easy use of the FPD for central venous punctures.

Animals↗
PubMed2007

[Intraosseous puncture in preclinical emergency medicine. Ten years experience in air rescue service].

INTRODUCTION: The intraosseous puncture (IO) is a fast and safe alternative to the puncture of peripheral veins in emergency situations in children < or =6 years of age. The purpose of this paper is to summarize 10 years of experience on the prehospital use of the IO method by the Helicopter Emergency Medical Service (HEMS) "Christoph 22", Ulm. MATERIALS AND METHODS: This was a retrospective study from 1 January 1996 to 31 December 2005. RESULTS: Out of a total of 9,549 missions, the proportion of children was 11.1%. In 27 children (4.2% of the children < or =6 years of age) an IO puncture was performed. Patients of the IO group were younger (1.0 vs. 3.7 years of age; p<0.001) and showed a higher degree of injury severity (NACA 6 vs. 4; p<0.001) compared to the total children group. In all children of the IO group (100%), the intraosseous puncture was the method of first choice to obtain access to the vascular system by the HEMS team. In 96.4% of these cases (26/27), the first IO puncture attempt was successful - in one child, a second puncture attempt was necessary. A standardized puncture technique was performed using the proximal tibia. The time required for successful placement of the IO infusion line was 60 s or less in all cases. In 37% of the cases (10/27) the IO infusion line was used for induction of general anaesthesia; dosage and onset of administered drugs were described as being equivalent to a peripheral infusion line. In all cases, the IO needle was replaced in-hospital within 2 h by a central or peripheral iv line. No complications were observed. CONCLUSIONS: The IO infusion technique is a simple, fast and safe alternative method for emergency access to the vascular system in children < or =6 years of age in the prehospital setting.

Aircraft↗
PubMed1993

Surgical glove punctures during cardiac operations.

A new method of detecting occult glove punctures was devised to determine its frequency during cardiac operations. Glove puncture is of relevance to the transmission of infectious diseases and the potential contamination of implanted cardiac prostheses. A study was therefore carried out in 48 adult patients undergoing open heart operations in which gloves worn by surgeons and nurses were collected and evaluated at the end of each procedure. In 22 of these cases, gloves were changed at three different stages of the cardiac operation for the principal operators: stage I, skin incision to commencement of cardiopulmonary bypass; stage II, cardiopulmonary bypass to sternotomy closure; and stage III, sternotomy closure to skin closure. One hundred sixty-two gloves (31.5%) had one or more punctures out of a total of 514 gloves tested. Only 20 glove punctures were recognized either at the time or at the end of the operation. There were 185 occult glove punctures. The majority (60%) of punctures were on the nondominant hand, with 30% of perforations located in the nondominant index finger. Using the chi 2 test with two degrees of freedom, there is no significant difference between the glove perforation rates for the principal operators in stages I, II, and III. The most important finding from this study was that 61% of gloves worn by scrub nurses had one or more punctures compared with 23.6% of surgeons.

Cardiac Surgical Procedures↗
PubMed1997

The incidence of artery puncture with central venous cannulation using a modified technique for detection and prevention of arterial cannulation.

BACKGROUND: Cannulation of the central circulation is essential for management of patients who require major surgery, and for patients who are critically ill. Arterial puncture is the most frequent complication associated with central venous cannulation, and is potentially fatal. Detection of arterial puncture can be problematic, especially in patients with cyanotic congenital heart disease. METHODS: One thousand eleven consecutive cardiothoracic and vascular surgical patients who required central venous cannulation were studied using a new technique for detection of arterial puncture and prevention of arterial cannulation. This technique involves continuous pressure transduction of the steel introducer needle. Central venous cannulation was attempted in all patients. The sites of attempted catheterizations, number of arterial punctures and cannulations, and the number of successful catheterizations were noted. All patients were treated in accordance with standard anesthetic and surgical techniques in the institution. RESULTS: One thousand one hundred seventy-two central venous catheters were placed. The overall success rate was 99.6%. The incidence of arterial puncture was 9.3% for central venous cannulation attempts of the internal jugular, subclavian, and femoral veins. No arterial cannulation occurred, and none of the patients had significant complications. Congenital heart disease patients had a higher incidence of arterial puncture (14.1%) and a lower rate (96.8%) of successful cannulation. CONCLUSION: Pressure transduction of the steel needle is a useful technique for detecting arterial puncture and preventing arterial cannulation during attempts to achieve central venous cannulation.

Adolescent↗
PubMed1989

[Metastases caused by fine needle puncture?].

Tumour cells appear spontaneously in the blood of tumour patients. However, the formation of metastases depends not only on the number of tumour cells, but also to a large degree on the defence status of the patient. According to the experiments presented here, fine needle puncture can slightly increase tumour cell migration. Tumour cells are carried through the puncture channel into the bloodstream; case reports show that in some cases the number of tumour cells mobilised in this manner may be sufficient to induce a metastatic growth at the site of puncture. However, practically all reported cases concerned advanced tumour stages. The puncture metastasis did not exercise any influence on the course of the disease or on the prognosis. The incidence of metastases in the puncture channel after fine needle biopsy of tumours of various organs is between 0.003 and 0.005% and is hence low. Nevertheless, indication for fine needle puncture of malignant processes should be considered very critically. However, if the use of the puncture leads one to expect therapeutic consequences that are of relevance for the patient, the doctor should not hesitate to employ this method which has a high informative value.

Biopsy, Needle↗
PubMed1987

[Therapeutic percutaneous puncture and drainage of postoperative space-occupying lesions using permanent ultrasound and roentgen control].

Ultrasonically guided, percutaneous fine-needle aspiration biopsy allows final histological and/or cytological diagnosis in patients with benign or malignant space-occupying growths even of small size. Therapeutic puncture and drainage of postoperative abdominal or retroperitoneal growths (haematoma, seroma, lymph cyst, abscess) however, requires 1.) dilatation of the percutaneously established puncture channel and 2.) continuous vacuum aspiration over a period of several days or weeks. We report on three therapeutic punctures in two patients with retroperitoneal lymph cysts following abdominal radical hysterectomy with lymphonodectomy and one patient with abscess formation following nephrectomy. The technique employed was as used in percutaneous nephrostomy. Under local anaesthesia and permanent ultrasound guidance the lesion is punctured with a 1.3 mm hollow puncture needle of three parts (Angiomed) and after aspiration of fluid a 0.9 mm wire guide with a curved, soft tap was inserted through the puncture needle in the lesion. The puncture channel is then dilated under x-ray visualisation with a Teflon-coated fasciadilatator (Cook) to Charr. 16 (20). Finally either a polyvinyl catheter with two lateral apertures (Cook) or a double-barrelled Shirley Drain is inserted and fixed to the skin with a stitch. For diversion a closed system is used. Over a period of one to two weeks 50 to 200 millilitres of secretion are drained off per day in decreasing quantity. The patients returned to normal temperature and recovered entirely. The advantage of our method is the avoidance of dangerous and difficult secondary surgery.

Abscess↗
PubMed2002

A new radial mechanical puncture echoendoscope: prospective comparison with standard linear and radial echoendoscopes in assessment of focal pancreatic lesions.

BACKGROUND: A new mechanical puncture-echoendoscope was evaluated by comparing it with conventional linear and radial echoendoscopes. The new instrument has a 300 degrees image field parallel to the axis of the echoendoscope, which could potentially improve accuracy and facilitate assessment of suspected pancreatic lesions before needle puncture. METHODS: Twenty consecutive patients with suspected pancreatic lesions were evaluated endosonographically, including fine needle aspiration (FNA). The initial assessment was performed by random selection of either the new instrument or the standard linear echoendoscope. After completing the assessment including FNA, the procedure with FNA was repeated with the other puncture echoendoscope. The findings with these 2 instruments were compared to those with the conventional radial scanning echoendoscope. RESULTS: FNA was performed in 17 patients with pancreatic head lesions. In 3 patients without a visible pancreatic mass lymph, nodes greater than 10 mm in diameter were aspirated. The ability to image the needle, number of punctures, and material obtained were comparable for both puncture echoendoscopes. There were no significant differences with regard to time required for FNA with both puncture echoendoscopes or in the assessment of surrounding structures with all 3 instruments. The results of cytopathologic evaluation of material obtained by FNA were similar in 15 cases. The new instrument could not be passed into the esophagus in 1 patient because of an esophageal stricture. CONCLUSIONS: The performance of the new mechanical puncture echoendoscope was satisfactory for assessment and FNA of pancreatic lesions. The additional use of the conventional radial scanning echoendoscope provided no advantage with regard to any parameter assessed.

Adult↗
PubMed2003

Repeated femoral vein puncturing for maintenance haemodialysis vascular access.

BACKGROUND: When access cannot be achieved using a native arteriovenous fistula or a synthetic prosthetic graft, central venous catheters are usually placed. This mode of access is short-lived, prone to infection, stenosis and thrombosis of central veins. To overcome access problems, we developed a new native vascular access ('femoral vein access') and devices. We report here on our experience with the availability, longevity, procedure and morbidity of haemodialysis (HD) using femoral vein access. METHODS: Repeated (three times a week) patient's native femoral vein puncturing has been used as the vascular access (femoral vein access) for maintenance HD in 30 patients (mean age +/- SD: 61.70 +/- 15.27 years old; 18 female/12 male). The femoral vein was punctured beneath the inguinal ligament (on a length ranging from 30 to 100 mm) after disinfection and local anaesthesia. Long (effective length 56 mm) 19- and 18-gauge needles with four side holes were used for the femoral vein puncture as an arterial site of the extracorporeal circuit of HD and shorter (effective length 40 mm) similar gauge needles for the subcutaneous vein puncture used as the return site. The needle is inserted blind into the femoral vein after the femoral artery has been located by palpation and the perception of a pulse. Patients returned home the same day. RESULTS: The mean duration of HD treatment using femoral vein repeated puncture was 4.99 +/- 3.42 years (up to 16.0 years). This represented a total experience of 23 369 femoral vein punctures. The mean blood flow achieved on dialysis was 165 +/- 20 ml/min. The average Kt/V was 1.74 +/- 0.48 per session. CONCLUSIONS: The femoral vein repeated puncture technique has substantial advantages over venous catheters. It does not require surgery, while permitting adequate blood flow. This method can be used as a long-term (over 10 years) blood access. Apart from a few local haematomas, no serious complications have been observed. Moreover, it does not carry a heavy financial burden.

Adult↗
PubMed2006

Navigation-based needle puncture of a cadaver using a hybrid tracking navigational system.

PURPOSE: The purpose of this study was to determine the puncture accuracy of a navigational system, Medarpa, in a soft tissue environment using augmented overlay imaging. MATERIALS AND METHODS: Medarpa is an optical electromagnetic tracking system, which allows tracking of instruments, the radiologist's head position, and the transparent display. The display superimposes a computed tomography scan of a cadaver chest on a human cadaver in real time. In group A, needle puncture was performed using the Medarpa system. Three targets located inside the cadaver chest were selected. In group B, the same targets were used to perform standard computed tomography-guided puncture using a single-slice technique. A total of 42 punctures were performed in each group. Postpuncture computed tomography scans were made to verify needle tip positions. RESULTS: Mean deviation from targets was 8.42 mm +/- 1.78 mm for group A and 8.90 mm +/- 1.71 mm for group B. No significant difference was found between group A and B in any target (P > 0.05). No significant difference was found between the targets of the same group (P > 0.05). Procedural time for 42 punctures was 160 minutes in group A versus 289 minutes in group B (P < 0.05). CONCLUSION: Needle puncture in a soft tissue environment using the navigational system Medarpa can be reliably performed and matches the accuracy achieved by a computed tomography-guided puncture technique.

Biopsy, Needle↗