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Lung Ultrasound (in the Critically Ill) Superior to CT: the Example of Lung Sliding

kjccm-2016-00955f1A recent article by Daniel A. Lichtenstein published in the Korean Journal of Critical Care Medicine (Korean J Crit Care Med 2017; 32(1): 1-8.) on comparing the use of ultrasound (US) for assessment and diagnosis of pneumothorax and whether it is superior to computerized tomography (CT).

Lung Ultrasound (in the Critically Ill) Superior to CT: the Example of Lung Sliding

Great article on Harvard Business Review – Conflict-of-Interest Rules Holding Back Medical Breakthroughs..

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A colleague of mine recently posted a link to this article, but I also thought it was a pertinent read. I actually couldn’t agree more. Health departments need to collaborate with industry and clinician experts to improve health outcomes and patient safety. Time to get out of the silos and listen to experts that don’t always work within healthcare departments.

“The big public health problems that humanity faces today — including Alzheimer’s disease, cancer, and metabolic and infectious disease — will not be solved by either sector working in a silo. But the interface between the two has never been more tense. Legitimate concerns over conflict of interest that have resulted in overly extreme preventative policies are a central cause. It is time for all parties to revisit those policies and replace them with rules that recognize both true conflicts and true confluences of interest. They are essential to forging the strong collaborations that are worthy of society’s trust.”

Conflict-of-Interest Rules Are Holding Back Medical Breakthroughs

Air Embolism – understanding WHY it occurs and HOW to prevent it

Air EmbolismAir Embolism (AE) is often a life-threatening complication of large bore intravascular device insertion and removal. Although much focus has been with the insertion phase, device removal is just as potentially dangerous.

There is becoming an increased awareness of AE through patient advocacy groups and from a patient safety perspective taught by experienced healthcare clinicians. There are more frequent publications related to AE and certainly this complication is getting a wider girth of awareness.

Essentially, ANY intravascular device – intravenous (IV) or intra-arterial (IA), can cause an AE. Although IA is potentially a lesser risk, it does not mean that it doesn’t occur.

Devices, particularly IV, should be removed with the patient satisfying the following criteria;

  1. The patient/client should be in a supine (flat) or slight Trendelenburg position (15-20° head-down) – particularly for CVADs and PICCs.
  2. Should be removed at end-expiration – for all devices.
  3. Should have an air-occlusive, paraffin or petroleum-based dressing over the removal site for 48 hours, until the exit site wound has sealed closed.

Many clinicians who remove these types of devices MUST be educated and aware of potential for AE to occur, and need to ensure that preventative measures are in place BEFORE a device is removed.

Following the three actions listed above will reduce the risk of AE in most situations.
An easy to remember way is to think, ‘the patient should be in the same position for removal of the device as for the insertion of the device’. Easy.

When air embolism is suspected, the patient should be placed on 100% oxygen and on the left lateral decubitus position, which may improve right ventricular outflow by keeping air in the right atrium or in the apex of the right ventricle, away from the pulmonary artery and right ventricular outflow tract.

AE should also be included during ‘mock’ codes – simulated scenarios for training purposes. This is one way of ensuring the education is met on a regular (or even mandatory) level within healthcare facilities for clinicians who are associated with intravascular device removal.

Here are several links to recent articles on air embolism prevention (courtesy of JVA);

Tunneled central venous catheter exchange: techniques to improve prevention of air embolism

Over-catheter tract suture to prevent bleeding and air embolism after tunnelled catheter removal

Cerebral air embolism after central dialysis line removal: the role of the fibrin sheath as portal (mechanism) of air entry

#vascularaccess #FOAMva