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PubMed2005

[Post lumbar puncture headache in general pediatrics: a prospective multicenter study].

PURPOSE: To investigate the frequency of post lumbar puncture headaches (PLPH) after diagnostic lumbar puncture (LP) and to search for influence factors. PATIENTS AND METHODS: Conducted over 6 months into 8 paediatric services, the study concerned 2 to 15 years old children. The LP technic (cannula gauge, bevel orientation, child position, reinsertion of the stylet) was standardised. For each child questionnaires were filled with the parents 3 and 8 days after LP for inquiring headaches, postural characteristics, length and clinical consequences. RESULTS: Among 84 charts, 71 were exploitable. PLPH were observed in 25% of children. The mean duration was 5.9 days, mean bed rest was 1.4 day and mean antalgic treatment 1.7 day. The frequency of PLPH was not significantly influenced by age and sex, neither by the qualification of the physician performing the LP. The frequency was significantly lower when LP execution was easy (19.6 vs. 46.7%; P < 0.05), and when the child had viral meningitis (8 vs. 34.8%; P < 0.05). CONCLUSION: We have found a more important frequency of PLPH than in previous paediatric studies. Clinical consequences justify other researches to precise influence factors and reduce the frequency of this complication.

Adolescent↗
PubMed2005

Epidural blood patch with allogeneic blood for post-dural puncture headache.

A parturient suffered post dural puncture headache following accidental dural puncture during attempted epidural anesthesia for cesarean section. Post partum fever was regarded as a contraindication to autologous epidural blood patch; compatible and infection-free allogeneic blood was therefore used with good effect and without apparent complications.

Adult↗
PubMed2005

Oral multidose caffeine-paracetamol combination is not effective for the prophylaxis of postdural puncture headache.

STUDY OBJECTIVES: To investigate the effects of different doses of oral caffeine-paracetamol combinations in postdural puncture headache (PDPH) prophylaxis. DESIGN: Prospective, randomized, placebo-controlled, blinded study. SETTING: University hospital. PATIENTS: A total of 210 ASA physical status I and II patients undergoing lower extremity surgery. INTERVENTIONS: Patients were randomly divided into 3 groups. One hour before the spinal anesthesia, the first group (n = 70) received placebo, the second group (n = 70) received 500-mg paracetamol + 75-mg caffeine, and the third group (n = 70) received 500-mg paracetamol + 125-mg caffeine orally. The same doses were repeated every 6 hours for 3 days. Patients were then interviewed on days 1, 2, 3, 4, and 7 to inquire about any PDPH. The interviewer was unaware of the PDPH prophylaxis group members. Patients who were discharged early were interviewed by telephone. MEASUREMENTS AND MAIN RESULTS: Postdural puncture headache occurred in 11 patients (15.7%) in group 1, 10 patients (% 14.28) in group 2, and 10 patients (% 14.28) in group 3. The differences between the groups were insignificant (P > .05). The complications due to spinal anesthesia were similar in the 3 groups. Side effects of caffeine such as lack of sleep, tachycardia, and hypertension were not observed in groups 2 or 3. CONCLUSIONS: Prophylactic administration of paracetamol-caffeine combinations at the stated doses does not prevent PDPH.

Acetaminophen↗
PubMed2005

Direct puncture capsulorhexis.

I describe a simple technique for performing capsulorhexis without viscoelastic material or expensive instruments. A slightly barbed, bent, 30-gauge needle is used to directly puncture clear cornea and create a capsulorhexis without the need for a groove or stab incision. Hydrodissection is carried out with the attached 1 cc syringe (tuberculin) filled with a balanced salt solution. Hydrodissection, hydrodelineation, and mobilization of the nucleus can be carried out before the eye is entered with a blade. With direct puncture, the technique is immune to the effects of high intraocular pressure and a shallow anterior chamber. The Technique is ideally suited for bimanual microincision phacoemulsification.

Capsulorhexis↗
PubMed2004

Reducing pain in ED patients during lumbar puncture: the efficacy and feasibility of iontophoresis, collaborative approach.

INTRODUCTION: This study examined the efficacy and feasibility of a collaborative iontophoresis procedure for dermal anesthesia prior to lumbar puncture (LP) in adult ED patients. METHODS: Patients were randomized to receive lidocaine by iontophoresis or needle infiltration. Emergency nurses and physicians completed a collaborative LP procedure in those randomized to iontophoresis. Usual care was provided for needle infiltration subjects. Pain was assessed at 3 points using an 11-point numeric rating scale to measure pain, and provider satisfaction was recorded. RESULTS: Ninety subjects completed the protocol: infiltration group (n = 48) and iontophoresis group (n = 42). Subjects in the lidocaine infiltration group reported significantly more pain (mean, 4.1A+/-2.6) than subjects in the iontophoresis group (mean, 0.9A+/-1.6) ( t82 = 1.26, P =.000). There was no significant difference between the pain experienced during the lumbar puncture by both groups. Mean pain score during LP was 3.7 (+/-2.7) for iontophoresis compared to 3.4 (+/-2.9) for infiltration. More iontophoresis subjects (18 or 43.9%) required "rescue" lidocaine than infiltration subjects (12 or 24.5%) (chi-square 1 =3.79, P =.0515). Providers reported greater satisfaction with the collaborative procedure compared to physician administered lidocaine infiltration and anecdotally reported that iontophoretic anesthesia administration does not obscure anatomical landmarks, as needle infiltration can. Time for completion of dermal anesthesia using the iontophoretic procedure was longer than time for completion of dermal anesthesia using the lidocaine infiltration procedure (12A+/-12 min vs 2A+/-1.7 min); however, no statistically significant difference in total LP time or ED length of stay was found. NURSING IMPLICATIONS: Dermal anesthesia by lidocaine iontophoresis in patients undergoing an LP with emergency nurses and physicians working in collaboration during the procedure takes longer, but decreases the pain of administering anesthesia, increases provider satisfaction, and fosters collaborative practice in the emergency setting. Iontophoretic administration of anesthesia for LP is now an option for dermal anesthesia in our emergency department.

Adolescent↗
PubMed2004

Cecal ligation and puncture with total parenteral nutrition: a clinically relevant model of the metabolic, hormonal, and inflammatory dysfunction associated with critical illness.

BACKGROUND: Standard rat cecal ligation and puncture (CLP) results in only transient hyperglycemia, making an examination of the effects of glucoregulatory agents, such as insulin, on the morbidity and mortality of CLP problematic. Accordingly, we sought to develop a model of rat CLP with prolonged hyperglycemia through continuous infusion of total parenteral nutrition (TPN) post CLP. MATERIALS AND METHODS: Polyethylene catheters were implanted into the femoral vein of female Sprague Dawley rats (245-265 g) which were subsequently subjected to CLP. TPN was initiated at different intervals following CLP, and mortality, bacteremia, blood glucose, hormonal, and inflammatory responses were monitored. RESULTS: Without TPN, CLP resulted in significantly lower blood glucose at 22 h post CLP. In contrast, CLP rats receiving TPN exhibited significant prolonged hyperglycemia that was responsive to insulin treatment. Mortality and hyperglycemia tended to increase with puncture size in CLP TPN rats, with early initiation of TPN leading to poorer outcome. There were time-dependent differences in bacteremia and mortality based on time of TPN initiation. Levels of insulin, leptin, and glucagon were significantly elevated in CLP TPN rats, as were many inflammatory markers. Organ damage was evident as early as 12 h post CLP and blood cell kinetics indicated significantly depressed neutrophil and lymphocyte counts. CONCLUSIONS: Our results indicate that addition of TPN to CLP provides a clinically relevant animal model of critical illness with associated hyperglycemia that may provide utility for the testing of glucoregulatory and other therapeutic modalities.

Animals↗
PubMed2006

Subclavian artery puncture repair with Angio-Seal deployment.

BACKGROUND: Inadvertent placement of a port-a-catheter in an artery during central venous cannulation is rare and can result in devastating complications. Although traditional closure devices have been employed as prompt and adequate treatment, more innovative devices such as collagen plugs are being studied for their efficacy. CASE: We report a case involving a 63-year-old woman who was treated with chemotherapy for recurrent metastatic uterine leiomyosarcoma. During port-a-catheter placement, puncture of the subclavian artery occurred. Vascular surgery and interventional radiology consultation was obtained, wherein an Angio-Seal device was used to seal the exit from the subclavian artery. Angio-Seal placement was successful and the patient has since become clinically stable and was then discharged. CONCLUSION: Subclavian artery puncture is rare but can occur due to the close proximity between the subclavian artery and vein. Prompt vascular surgery and radiology consultation is necessary. Although traditional manual compression and closure devices have been effective at restoring hemostasis, collagen seals or plugs may be more viable to treat this precarious situation.

Catheterization, Central Venous↗
PubMed2000

Suture closure of femoral arterial puncture sites after coronary angioplasty followed by same-day discharge.

BACKGROUND: The purpose of this study was to determine whether immediate suture closure of 8F femoral arterial puncture sites can facilitate same-day discharge after coronary angioplasty. METHODS AND RESULTS: After coronary angioplasty, 100 patients were randomly assigned to immediate sheath removal with the double-suture Prostar-Plus device or delayed sheath removal with application of a c-clamp. After suture closure, mobilization at 4 hours after sheath removal and discharge 4 hours later were planned. Patients treated with the c-clamp had sheaths removed 4 hours after percutaneous transluminal coronary angioplasty, were mobilized 6 hours later, and discharged the following day. Patients were assessed for groin complications at 8, 24, and 72 hours. Overall, patients who received suture closure were mobilized at 7.1 +/- 5.3 hours and discharged 11. 15 +/- 6.22 hours after sheath removal versus 15.49 +/- 3.9 hours and 21.9 +/- 3.8 hours for patients with the c-clamp (P <.001). Initial failure of the suture device occurred in 5 patients, with 1 requiring surgery for an entrapped device. After the procedure, patients with suture closure more frequently had an ooze of blood (55% vs 24%, P <.001) and a trend to more overt external bleeding (10% vs 2%, P = not significant). Hematomas were reported by 20% of patients in both groups at 72 hours. Overall, patients preferred the suture closure method of sheath removal when assessed by a simple questionnaire. An economic analysis by cost minimization demonstrated potential hospital cost saving. CONCLUSIONS: Suture closure of 8F arterial puncture sites can facilitate early mobilization and same-day discharge and is considered acceptable by more patients compared with application of the c-clamp. There is potential to realize cost savings with a strategy of same-day discharge.

Angioplasty, Balloon, Coronary↗
PubMed1993

Multifetal pregnancy reduction by transvaginal puncture: evaluation of the technique used in 134 cases.

OBJECTIVE: This report reviews multifetal pregnancy reductions performed transvaginally and tests the feasibility and associated pregnancy loss rates with this technique. STUDY DESIGN: One hundred thirty-four consecutive multifetal pregnancy reductions were analyzed regarding different aspects of total pregnancy losses and complications. The first 40 manually performed were compared with the last 94 procedures performed with an automated puncture device and a thin needle. The losses were also analyzed as a comparison of the reduction of the lower-lying with the higher-lying fetuses located in relation to the internal os. RESULTS: A total uncorrected total pregnancy loss rate of 12.6% and a corrected loss rate of 10.6% was observed. Of the 112 pregnancies in which the lower-lying fetus was reduced, 11 losses were seen. The loss rate in the group reducing the upper fetus was three of 22. The manual versus the puncture device groups showed the same loss rate (10%); however, the manual group had a larger number of subchorionic hematomas after the procedure. CONCLUSIONS: The data are indicative of a very low maternal complication rate (infection) and an acceptable loss rate of the entire pregnancy. The loss rates compare favorable with those for multifetal pregnancy reduction performed transabdominally.

Abortion, Induced↗
PubMed2004

A protein C deficiency exacerbates inflammatory and hypotensive responses in mice during polymicrobial sepsis in a cecal ligation and puncture model.

During the systemic inflammatory state induced by sepsis, the potential for coagulopathy exists because of up-regulation of natural procoagulants and anti-fibrinolytics, and down-regulation of natural anti-coagulants, with protein C (PC) being a critical example of the latter case. PC functions as an anti-coagulant, profibrinolytic, and anti-inflammatory agent, and, thus, its administration or deficiency may affect the course and outcome of sepsis in patients. In this study, a cecal ligation and puncture model of septic peritonitis was applied to wild-type mice and littermates with a targeted heterozygous deficiency of PC (PC(+/-)) to characterize the importance of a PC-deficiency on polymicrobial sepsis. An enhanced mortality rate was found to accompany a PC deficiency. Plasma cytokines, as well as organ-specific expression of cytokine transcripts, were elevated in PC(+/-) mice. No signs of severe disseminated intravascular coagulation (DIC) were observed in wild-type or PC(+/-) mice, as indicated by an increase in fibrinogen levels and the invariability of platelet counts after cecal ligation and puncture. Consumption of coagulation factors was similar in both genotypes and a decrease in the PC mRNA and protein levels was more prominent in PC(+/-) mice. Renal and organ muscle damage was enhanced in PC(+/-) mice, as shown by increases in plasma blood urea nitrogen, creatinine, and creatinine kinase. Hypotension and bradycardia were more enhanced in PC(+/-) mice than in wild-type mice, thus provoking a more severe septic shock response. Thus, the hemodynamic role of PC during sepsis is of critical importance to the outcome of the disease.

Animals↗
PubMed1988

Immediate tracheoesophageal puncture for voice restoration in laryngopharyngeal resection.

A 2-year prospective study on primary tracheoesophageal puncture was carried out to evaluate the morbidity of the procedure and its success in restoring speech. Fifty-two patients, 36 of whom suffered from carcinoma of the larynx and 16, carcinoma of the hypopharynx, were entered into the study. Thirty-three patients underwent total laryngectomy with primary pharyngeal closure, 14 patients had, in addition, pharyngectomy and pectoralis major myocutaneous flap reconstruction, and 5 patients had pharyngolaryngoesophagectomy and gastric transposition. Tracheoesophageal or tracheogastric speech was successful in 58, 86, and 80 percent, respectively. Manometric studies showed that the neopharyngeal sphincter pressure decreased in all instances, but a correlation between the neopharyngeal pressure and the success of tracheoesophageal speech was not demonstrable. The morbidity rate related to tracheoesophageal puncture was low. Therefore, we believe it to be a safe and feasible procedure that can facilitate early voice restoration.

Adult↗
PubMed1998

Percutaneous femoral puncture for endovascular treatment of occlusive arterial lesions.

BACKGROUND: Percutaneous femoral arterial access is a most important and difficult aspect of endovascular intervention, and the source of most complications. METHODS: A retrospective review was made of the authors' 9-year experience with 755 femoral punctures for the endovascular treatment of occlusive disease. The main focus was the evolving success rate with percutaneous arterial entry and the incidence of access-related complications. RESULTS: Cutdowns were frequent during the first 2 years, 54% and 17%, respectively, decreasing to 5% or lower by the third year. The incidence of femoral hematoma and other complications mirrored the same learning curve. After cutdown, wound infections and lymph leakage occurred in 2.4% each, and prolonged significant pain in 5%. CONCLUSIONS: Percutaneous puncture is a crucial skill in endovascular intervention. Practicing vascular surgeons can expect a significant learning curve. Performance can be optimized through intensive basic and advanced training and preceptorship. The cutdown approach is neither necessary nor acceptable for most endovascular procedures.

Arterial Occlusive Diseases↗
PubMed1999

The use of the angio-seal haemostatic puncture closure device in high risk patients.

The use of the Angio-Seal haemostatic puncture closure device in 45 patients considered to be at increased risk of puncture site complications is described. Successful device deployment occurred in 44 of 50 arteries (88%). Two major complications were associated with, but not necessarily caused by, the Angio-Seal device. Four minor complications were observed. In a subset of 23 patients well enough to mobilize early after their procedure, 17 did so at an average of 2.6 h as opposed to the routine 12-18 h for patients after a procedure involving a 6-8F sheath. Once the initial learning curve has been overcome, the Angio-Seal device is a simple and successful method of achieving arterial haemostasis following catheterization and is associated with a low risk of complications. At present we would recommend its use for high risk patients only, as manual compression is effective in the majority of routine cases.

Aged↗
PubMed1989

Transvaginal pulsed Doppler measurement of blood flow velocity in the ovarian arteries during cycle stimulation and after follicle puncture.

In experimental studies, an increase of the ovarian blood flow was found during cycle stimulation. In this study, the authors performed transvaginal pulsed Doppler measurements of the ovarian arteries in stimulated cycles before and after follicle puncture. Four days before follicle puncture, high flow velocities in systolis were found compared with diastolis. Toward the day of embryo transfer, a marked increase of the diastolic blood flow velocity was observed. In patients with high endocrine response, the pulsatility index (PI) was significantly lower compared with that of patients with low endocrine response. The technique of transvaginal pulsed Doppler measurements offers the possibility to study the alterations of the ovarian blood flow under physiologic and pathophysiologic conditions.

Adult↗
PubMed2001

Radioisotope blood volume measurement in uncontrolled retroperitoneal haemorrhage induced by a transfemoral iliac artery puncture.

Standard-of-care, large volume crystalloid infusion, in the setting of uncontrolled bleeding, has been challenged and it is not known if fluid resuscitation increases retroperitoneal hemorrhage. We developed an experimental model of retroperitoneal haemorrhage to correlate haemodynamic and metabolic alterations with the blood volume loss. Anaesthetised, spontaneously breathing dogs (17.1+/-0.56 kg) were randomised to unilateral (UL, n=11) or bilateral (BL, n=11) iliac artery puncture, using a metallic device introduced through the femoral arteries and followed for 120 min. Initial and final blood volumes were determined using radioactive tracers, 99mTC and 51Cr, respectively. UL was associated with a stable arterial pressure and a moderate decrease in cardiac output and oxygen delivery. BL induced an abrupt and sustained decrease in mean arterial pressure, from 131.9+/-5.9 to 88.6+/-10.8 mmHg, and a much greater reduction in cardiac output, oxygen delivery and consumption than UL throughout the experiment. Total retroperitoneal blood loss after BL was 36.8+/-3.2 ml/kg, while after UL was 25.1+/-3.4 ml/kg (P=0.0262). We conclude that a transfemoral bilateral iliac artery puncture produces a clinically relevant model of uncontrolled retroperitoneal haemorrhage, with hypotension and low flow state, while a unilateral iliac artery lesion causes a compensated shock state.

Animals↗
PubMed1985

Serial lumbar punctures in prevention of post-hemorrhagic hydrocephalus in preterm infants.

We studied 47 infants with either grade 3 or grade 4 intraventricular hemorrhage, to assess the efficacy of intermittent lumbar punctures in the prevention of post-hemorrhagic hydrocephalus in a prospective controlled trial. The control group received supportive care only, whereas the treatment group additionally underwent intermittent spinal taps. The spinal taps were started at postnatal age 11 +/- 5 days and continued for 20 +/- 16 days, with the removal of 67 +/- 101 ml cerebrospinal fluid using 16 +/- 12 taps. The two groups were comparable with regard to birth weight, gestational age, race, sex, Apgar score, and severity of hemorrhage. Three infants in the control group died, compared with two infants in the study group. Nine infants in the control group and 10 infants in the study group developed hydrocephalus requiring a ventriculoperitoneal shunt or a ventricular catheter reservoir. These differences in the outcome in the two groups are not statistically significant. We conclude that serial lumbar punctures were unsuccessful in prevention of hydrocephalus in this group of preterm infants with intraventricular hemorrhage.

Cerebral Hemorrhage↗
PubMed2003

Metalloproteinase inhibition reduces lung injury and improves survival after cecal ligation and puncture in rats.

BACKGROUND: Neutrophil activation with concomitant matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9) release has been implicated in the development of sepsis-induced acute lung injury. We hypothesized that COL-3, a chemically modified tetracycline known to inhibit MMP-2 and MMP-9, would reduce lung injury and improve survival in rats following cecal ligation and puncture (CLP). METHODS: Sprague-Dawley rats were separated into five groups: 1) sham CLP+ carboxymethylcellulose (CMC; vehicle for COL-3, n = 6); 2) sham CLP + COL-3 (n = 6); 3) CLP + CMC (n = 10); 4) CLP + single-dose (SD) COL-3 administered concomitant with CLP (n = 9); and 5) CLP + multiple-dose (MD) COL-3 administered concomitant with CLP and at 24 h after CLP (n = 15). Rats were sacrificed at 168 h (7 days) or immediately after death, with survival defined as hours after CLP. Histological lung assessment was made based on neutrophil infiltration, alveolar wall thickening, and intraalveolar edema fluid. Lung MMP-2 and MMP-9 levels were assessed by immunohistochemistry. MMP-2 and MMP-9 levels were correlated with survival by simple regression analysis. RESULTS: The mortality of rats in the cecal ligation and puncture without treatment group (CLP + CMC) was 70% at 168 h. A single dose of COL-3 in the CLP + COL-3 (SD) group significantly reduced mortality to 54%. Furthermore, with a repeat dose of COL-3 at 24 h after CLP, mortality was significantly reduced to 33%. Pathologic lung changes seen histologically in the CLP + CMC group were significantly reduced by COL-3. A significant reduction in lung tissue levels of MMP-2 and MMP-9 was noted in both groups treated with COL-3. Reduction of MMP-2 and MMP-9 levels correlated with improved survival. CONCLUSION: Inhibition of MMP-2 and MMP-9 by COL-3 in a clinically relevant model of sepsis-induced acute lung injury reduces pulmonary injury and improves survival in a dose-dependent fashion. Our results suggest that prophylactic treatment with COL-3 in high-risk patients may reduce the morbidity and mortality associated with sepsis-induced acute respiratory distress syndrome.

Animals↗
PubMed1977

Arteriography before needle puncture or renal hilar lesions.

We report on 2 patients with cystic-appearing lesions in the renal hilus that were detected on urography. In 1 case an ultrasound study confirmed a cystic mass but an arteriogram revealed a renal artery aneurysm. The arteriogram before the contemplated puncture of the renal hilar mass prevented an inadvertent puncture. The information about the arterial anatomy helped preoperative planning, which resulted in successful repair of the aneurysm by microdissection and autotransplantation.

Adult↗