Complications in Minor Procedures

1. Complications in Minor Procedures Directed by Dr.M.A.Sahebi

2. The decision to obtain central venous access must be a thoughtful one, and the data regarding the risk and cost of complications must be underscored. Steps to decrease complications include the following: • 1.Ensure that the patient's condition indeed warrants central venous access. Experienced personnel should insert the line with proper positioning and sterile technique. Controversy exists as to whether or not placing the patient in Trendelenburg position facilitates access.

3. Central Venous Access Lines • 2.Antibiotic-coated catheters may decrease the rate of central line sepsis, although they initially are more expensive 3.Routine central line changes should not be performed, and the lines should be removed as soon as adequate peripheral intravenous access can be established for medications that do not require central access.

4. One of the most common complications of central venous access is pneumothorax. It is not just inexperienced clinicians that create these iatrogenic injuries, but pneumothorax rates appear to be higher among the inexperienced. Pneumothorax occurrence rates from both subclavian and internal jugular vein approaches are on the order of 1 to 6%.

5. ` • The first step in prevention is proper positioning of the patient during the procedure. Even if a pneumothorax is not suspected to have occurred during the procedure, a chest x-ray is still needed to confirm the presence or absence of a pneumothorax following the line insertion.

6. The decision regarding the need for a thoracostomy tube is similar to that described for bronchoscopy; if the patient is stable, then expectant observation may be adequate, but if any concerns about the patient's clinical condition exist, a thoracostomy tube should be placed.

7. Occasionally, a delayed presentation of pneumothorax will manifest as late as 48 to 72 hours after central venous access attempts. This usually creates significant clinical compromise such that a tube thoracostomy is required.

8. Other complications that bear mentioning for both central venous and pulmonary artery catheters include transient arrhythmias during catheter insertion, arterial puncture with hematoma formation or persistent bleeding, and occasionally loss of a guidewire in the vena cava.

9. Arrhythmias (the most common complication) result from myocardial irritability secondary to the guidewire placement, and usually will resolve when the catheter or guidewire is withdrawn from the right heart.

10. Arterial puncture with bleeding can be troublesome, but the majority will resolve with direct pressure on or near the arterial injury site. It is only the rare case that will require angiography, stent placement, or surgery to repair the puncture site, but these patients usually will do well following the procedure, and have no significant arterial abnormalities over the long term

11. A lost guidewire or catheter now can be readily retrieved with interventional angiography techniques, and no longer represents an automatic need for surgical exploration to retrieve the lost material.

12. Another error with central access lines involving either a venous line or a pulmonary artery line is that of air embolus. These are estimated to occur in 0.2 to 1% of patients. However, when an air embolism does occur, the results often can be dramatic and mortality can reach 50%. Treatment may prove futile if the diagnosis is ignored, especially if the air embolism bolus is larger than 50 mL.

13. Clinical auscultation over the precordium often is nonspecific, so a portable chest x-ray may be required if the patient will tolerate the procedure. Nonetheless, aspiration via a central venous line accessing the heart may assist in decreasing the volume of gas in the right side of the heart, and minimize the amount traversing into the pulmonary circulation

14. Maneuvers to entrap the air in the right heart include placing the patient in the left lateral decubitus position and in Trendelenburg position, so the entrapped air can then be aspirated or anatomically stabilized within the right ventricle..

15. The advantage of the operative approach is that the resources needed to salvage the patient are more readily available in the operating suite, should there be an acute deterioration in the patient's condition.

16. perhaps the most dreaded complication of the pulmonary artery catheter is a pulmonary artery rupture. There usually is a sentinel bleed noted when a pulmonary artery catheter balloon is inflated, and then the patient begins to have uncontrolled coughing with hemoptysis..

17. Reinflation of the catheter balloon is the initial step in management, followed by immediate airway intubation with mechanical ventilation, an urgent portable chest x-ray, and notification of the operating room that an emergent thoracotomy may be required.

18. If there is no further bleeding after the balloon is reinflated, and the x-ray shows no significant consolidation of lung fields from ongoing bleeding and the patient is easily ventilated, then a conservative nonoperative approach may be considered

19. This approach might include observation alone if the patient has no signs of bleeding or hemodynamic compromise; however, more typically today a pulmonary angiogram with angioembolization or vascular stenting is the next step in treatment.

20. For hemodynamically unstable patients after pulmonary artery rupture, unless the patient is already in the operating room having thoracic surgery, attempts at salvaging these catastrophic situations often is unsuccessful because of the time needed to perform the thoracotomy and identify the branch of the pulmonary artery that has ruptured.

21. Another complication that may well be underreported is central venous line infections. 1–4 The Centers for Disease Control and Prevention (CDC) reports mortality rates of 12 to 25% when a central venous line infection becomes systemic, and this carries a cost of approximately $25,000 per episode.

22. The CDC does not recommend routine central line changes, but when the clinical suspicion is high, the site of venous access must be changed. Additionally, nearly 15% of hospitalized patients will acquire central venous line sepsis (defined as >15 colony-forming units [CFU] on an agar roll plate, or >103 CFU on sonication).

23. In many instances, once an infection is recognized as central line sepsis, removing the line is adequate. Staphylococcus aureus infections, however, present a unique problem because of the potential for metastatic seeding of bacterial emboli. The treatment for this situation is 4 to 6 weeks of tailored antibiotic therapy

24. Arterial Lines • Arterial lines are placed to facilitate arterial blood gas draws and to optimize hemodynamic monitoring. They often are not removed when central venous access is not in place so ongoing phlebotomy can easily be performed, a practice that may lead to higher complication rates.

25. Arterial access is preferably obtained via a sterile Seldinger technique, and a variety of arteries are utilized, such as the radial, femoral, brachial, axillary, dorsal pedis, and superficial temporal arteries

26. complications generally occur less than 1% of the time, when present they can be catastrophic. Complications include arterial spasm, bacteremia, thrombosis (the most common complication), bleeding (second most common), hematoma, pulselessness, and infection (0 to 10%). .

27. One could argue that should thrombosis or distal embolization occur, a hand is more precious than a foot, yet the literature suggests that the risk is nearly the same for both femoral and radial cannulation. This also is true for infection rates between the two sites as well.

28. For complications related to thrombosis, bleeding, and infected catheters with bacteremia, the catheters should all be removed and direct pressure placed for 5 to 10 minutes following removal.

29. Thrombosis with distal tissue ischemia often can be treated with anticoagulation, but occasionally a surgical intervention is required to reestablish adequate inflow. The occurrence of pseudo-aneurysms and arteriovenous fistulae is remarkably low for these catheters.

30. Endoscopy and Bronchoscopy • For gastrointestinal endoscopy, the most dreaded risk is perforation. Perforation may occur for 1:10,000 patients with endoscopy alone, but carries a higher incidence rate when performed with biopsy (0 to 30%).

31. This increased risk often occurs due to complications of intubating a gastrointestinal diverticulum (either esophageal or colonic), and also from the presence of weakened tissue in the wall of the intestine related to an inflammatory response secondary to infection (e.g., diverticulitis) or glucocorticoid use (e.g., inflammatory bowel disease).

32. Recognition that a perforation has occurred often is straightforward, but on occasion may be difficult. Patients will usually complain of diffuse abdominal pain shortly after the procedure, and then will quickly progress with worsening abdominal discomfort on examination.

33. For patients that are difficult to evaluate, a change in clinical status may take several hours, and occasionally as long as 24 to 48 hours, to become manifest. When concern for a perforation exists, the patient should immediately have radiologic studies to assess for free intraperitoneal air, retroperitoneal air, or a pneumothorax.

34. A delay in diagnosis of an endoscopic perforation creates the potential for ongoing gastrointestinal contamination and systemic sepsis

35. Recognition that a perforation has occurred often is straightforward, but on occasion may be difficult. Patients will usually complain of diffuse abdominal pain shortly after the procedure, and then will quickly progress with worsening abdominal discomfort on examination.

36. Treatment for a gastrointestinal endoscopy perforation is usually surgical exploration to locate the perforation, decontaminate the surrounding tissues, and then to surgically close the perforation site. The exact type of surgery depends on the site of perforation and the degree of contamination or sepsis that is found at surgery.

37. There are some patients in whom surgical exploration is not required; however, these are the exception rather than the rule. The patient who may be a candidate for nonoperative management usually is one for whom suspicions for perforation arise during an elective, bowel-prepped, endoscopy, and yet the patient does not have significant pain or clinical signs of perforation.

38. With the concern for perforation, an x-ray is usually performed that then shows free air. If the patient remains without significant pain and with a benign abdominal exam, then this type of patient may be observed in a monitored setting, kept on strict dietary restriction, placed on broad-spectrum antibiotics, and closely observed for 48 to 72 hours to detect any deterioration in clinical status.

39. If the patient remains with an uneventful course, a diet is gradually increased and the antibiotics discontinued after 3 to 7 days. If the patient clinically deteriorates at any time, immediate surgery is required.

40. Bronchoscope, however, has several indications but relatively less-severe complications compared with perforation. Indications for bronchoscopy include removal of foreign bodies, biopsy for cancer, difficult intubations, diagnosis for pneumonia, and delivery of medications.

41. The contraindications are relatively few and include a partial arterial pressure of oxygen (PO2) less than 60 mm Hg on 100% supplemental oxygen, an evolving myocardial infarction, and therapeutic anticoagulation.

42. The complications of bronchoscopy include bronchial plugging (the most common complication), hypoxemia, pneumothorax, lobar collapse, and bleeding. When each of these is diagnosed appropriately and in a timely fashion, they are rarely life-threatening

43. bleeding is usually quick to resolve and rarely requires surgery, but occasionally may require repeat endoscopy for thermocoagulation or fibrin glue application. The presence of a pneumothorax necessitates placement of a thoracostomy tube only when significant oxygenation deterioration occurs or the pulmonary mechanics are significantly compromised;

44. otherwise expectant observation is adequate. The presence of a lobar collapse or mucous plugging usually will respond to aggressive pulmonary toilet, but occasionally requires repeat bronchoscopy.

45. Tracheostomy

46. One of the oldest operations performed is that of the tracheostomy, and when performed correctly, it leads to decreased ventilator days, decreased length of intensive care unit (ICU) or hospital stay, and improved pulmonary toilet. Tracheostomies are now performed open, percutaneously, with or without bronchoscopy, and with or without Doppler guidance, and yet complications still arise.

47. Some of the complications tend to be minor and include changes in levels of partial pressure of arterial carbon dioxide (PCO2), radiographic changes in the postprocedure x-rays, and minor fluctuation in the pulse oximetry saturation levels

48. The indications for tracheostomy are important when deciding how and when to commit to a surgical airway. Historically, those patients on a moderate to high level of positive end-expiratory pressure (PEEP) have been considered not to be the best candidates for early tracheostomy for various reason

49. Hypercarbia is known to contribute to intracranial hypertension for traumatic brain injury patients. Using fiberoptic bronchoscopy (FOB) in percutaneous tracheostomy will contribute to hypercapnia if the endotracheal tube (ET) is small (<7.5 mm), or if the minute ventilation is such that adequate ventilation is not administered during the procedure

50. A recent study examined PEEP and hypoxemia at 1 and 24 hours postprocedure. The study concluded that it was safe to perform percutaneous dilatational tracheostomy on patients with high PEEP settings because the patients did not have adverse oxygenation at 1 and 24 hours status postprocedure. 5