Anaesthesia, 2003, 58, pages 911–935
Correspondence
....................................................................................................................................................................................................................
.
15 411 patients who had non-cemented
procedures.
The Ôon-tableÕ mortality in the frail
population who experience fractured
neck of femur (7% in-hospital 30-day
mortality; only 50% discharged home
clinical features of fat embolism during Thankfully, this affected only the distal
cemented total hip arthroplasty.
A randomised study in patients with a
femoral neck fracture. Archives of
Orthopaedic and Trauma Surgery 2000;
120: 53–8.
line, which had ruptured outwards,
leaving other lumens intact.
The subsequent investigation reve-
aled that the pressure infuser had mon-
itored the line pressures. It had failed at
a peak of 200. However, this was not the
expected measurement of 200 mmHg
or 4 pounds per square inch (psi) in fact,
the imaging injection systems are calib-
rated in the radiologists’ normal work-
ing units, psi and this gives a line fail
pressure of 10 482 mmHg. As a com-
parison, the usual infusion pumps
by 4 weeks [8]) is different between 8 Anon. http://www.wales.gov.uk.
patients having cemented and non-
cemented hemi-arthroplasty. Shouldn’t
Problems with the rapid
powered injection of radiology
contrast through multilumen
catheters
we all try to communicate more effect-
ively pre-operatively with our ortho-
paedic colleagues (as in two of the
centres above), and perhaps use less
cemented prostheses?
A recent incident involving a patient
undergoing contrast enhanced compu-
ted tomography (CT) highlighted a
potentially widespread, previously
unreported problem in the imaging of
critically ill patients. This is the use of
rapid, powered, contrast infusions
through multiple-lumen central lines,
leading to line rupture.
TM
TM
(Braun
and Graseby ) used on
G. Parry
our intensive care unit have occlusion
alarm, which cannot be set higher than,
or bypassed above. 9 psi. Kimal plc, the
company responsible for Arrow line
distribution, state that the lines are
quality tested to 25 psi, but do not
recommend use above 10–15 psi.
Vancouver General Hospital,
Vancouver V5Z 1M9, Canada
E-mail: gparry@vanhosp.bc.ca
References
1
Pitto RP, Koessler M, Kuehle JW.
Comparison of fixation of the femoral
component without cement and fix-
ation with use of bone-vacuum
It is possible that the line was ÔkinkedÕ
or occluded. However, there were no
signs that this was the case. The
norepinephrine infusion pump had not
alarmed, the distal lumen flushed well
from the pressure bag (300 mmHg) and
a good central venous waveform had
been obtained. The line had been
inserted via the straightest path, into
the right internal jugular vein. The head
had remained in the neutral position. It
is a moot point whether the pressure
limit should be set to cope with such
events, within the safety limits of the
line.
The patient involved was stable, but
required multiple organ support. He
was sedated, ventilated, on vasopressor
support and, prior to the scan, was
undergoing renal support. The scan, to
look for a possible septic focus, was
performed with 100 ml of warmed
Iomeron 300 iodinated contrast. This
cementing technique for the prevention
of fat embolism during total hip
arthroplasty. A prospective randomised
trial. Journal of Bone and Joint Surgery-
American 1999; 81: 831–43.
2
3
4
Murphy P, Edelist G, Byrick RJ, Kay
JC, Mullen JB. Relationship of fat
embolism to haemodynamic and
echocardiographic changes during
cemented arthroplasty. Canadian Journal
of Anaesthesia 1997; 44: 1293–300.
Byrick RJ, Kay JC, Mullen JB.
was infused via the 16G distal port of an
TM
Arrow-Howes
venous catheter placed in the right
Quad lumen central
TM
internal jugular vein. A Medrad
timed pressure injection device was
used to achieve
)
a
bolus rate of
ml.s . The scan was performed and
1
3
Capnography is not as sensitive as pul-
monary artery pressure monitoring in
detecting marrow microembolism.
Studies in a canine model. Anesthesia
and Analgesia 1989; 68: 94–100.
A Medline literature search revealed
that references to ÔsafeÕ use of central
venous catheters relate to use of larger
indwelling ÔHickmanÕ lines or non-
multiple lumen catheters, rated up to
100 psi [1–3]. Angiography catheters
are available rated up to 400 psi and so
most contrast pressure injection systems
are capable of delivering these pressures.
We were unable to find details of the
comparative degradation of image qual-
ity, or its effect on diagnostic accuracy,
that may result from lower infusion
rates due to pressure limiting. Bench
research is underway to assess the in vitro
performance of common multiple-
lumen catheters available in the UK.
A telephone poll of radiology units in
our region revealed that the injectors
were routinely set with the pressure
the patient remained stable. However,
the postcontrast scan images showed
little sign of enhancement. The reason
was plainly apparent upon flushing the
contrast line to check for disconnection.
As can be seen from Fig. 5, the line had
failed within the multiple-lumen hub.
Christie J, Robinson CM, Pell AC,
McBirnie J, Burnett R. Transoesopha-
geal echocardiography during invasive
intramedullary procedures. Journal of
Bone and Joint Surgery-British 1995; 77:
4
50–5.
5
6
Miller. Anaesthesia, 5th edn. Philadel-
phia: Churchill Livingstone, 2000.
Parvizi J, Holiday AD, Ereth MH,
Lewallen DG. The Frank Stinchfeild
Award. Sudden death during primary
hip arthroplasty. Clinical Orthopaedics
and Related Research 1999; 369: 39–48.
Pitto RP, Blunk J, Kossler M. Trans-
esophageal echocardiography and
7
Figure 5
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2003 Blackwell Publishing Ltd
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