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Air Embolism during Tunneled Central Catheter Placement Performed without General Anesthesia in Children: A Potentially Lethal Complication
Letters to the Editor Air Embolism during Tunneled Central Catheter Placement Performed without General Anesthesia in Children: A Potentially Lethal Complication From: Ziv J Haskal, MD Departments of Radiology and Surgery New York Presbyterian Hospital (Columbia Presbyterian) 177 Fort Washington Ave New York, NY 10032 Editor: I enjoyed reading Drs. Morello et a1 instructive article in the recent Interventionalist at Work (1). There is one additional useful technique for preventing air embolism during the introduction of tunneled central venous catheters. I ask the patients to hum during the brief period during which the peel-away sheath dilator is removed and the catheter is introduced. In some cases, we all hum along with the patient to encourage them. When the patient is humming, they are, of necessity, exhaling and thus prevented from drawing air through the sheath. I have found this to be easier than explaining a Valsalva maneuver and ensuring that it is maintained during the catheter introduction. While this maneuver will have little utility in young children, it may be of benefit to clinicians placing these catheters in older patients. Reference 1. Morello FP, Donaldson JS, Saker MC, Norman JT. Air embolism during tunneled central catheter placement performed without general anesthesia in children: a potentially lethal complication. JVIR 1999; 10:781-784.
Effectiveness and Complications of Treating Neuroendocrine Metastases, Embolization versus Chemoembolization From: George G. Hartnell, FRCR Department of Radiology and Radiological Science Johns Hopkins University Hospital 600 Wolfe Street Blalock 546 Baltimore, Maryland 21287 Editor: Dr. Brown and her colleagues are to be congratulated on the results they report for treatment of hepatic neuroendocrine metastases by particle embolization (1).Although the results are clearly very good, a number of points made in their Discussion section require comment. One point concerns the issue of complications and duration of hospital stay when compared with treatment with chemoembolization as previously reported by Perry et a1 (2) and Clouse et a1 (3). Brown et al. state that, with better case selection, they would have achieved a lower complication rate than has been reported for chernoembolization.
This is not surprising-we could all improve our complication rates with the aid of retrospective patient selection. This applies as much to chernoembolization as any other embolization. However, Brown et a1 (1)report a patient mortality of 12% (4 of 35 patients) which seems to be significant compared with the zero mortality reported by Clouse et a1 (3) for chernoembolization of neuroendocrine metastases. Twelve percent mortality is also much higher than the overall 2% procedural mortality for a much larger group of chemoembolizations (251) for all tumor types, reported from the same institution (4). Another issue is that when discussing historic data as reported by Perry et a1 and Clouse et al, they are looking a t a moving target. The studies cited refer to experience including patients treated some years ago. In particular, the reported length of stay no longer represents what is expected of the best current practice. Working with Drs. Perry and Clouse in the same institution in 1996 and 1997, we were able to achieve much shorter average hospital stays. In the first quarter of 1996, the mean hospital stay for all patients undergoing chernoembolization was 67.5 hours, and for the first quarter of 1997, the mean length of hospital stay had been reduced to 53.5 hours. For chernoembolization of neuroendocrine metastases, mean length of hospital stay for the first quarter of 1997 was 46.7 hours (5). Brown et a1 rightly point out the limitations of their study, including the retrospective nature of the study. As they acknowledge, there was some lack of clarity about the outcomes of some embolizations, with incomplete data available. Therefore, although the results suggest that the longevity achieved by particle embolization may be an appropriate way of treating hepatic neuroendocrine metastases, the case is not as strong as they would suggest. Indeed, with their high mortalitv rate. com~aredwith that repoked elsewhere, and longer me& av&age hospital stay (5.6 days compared with the 2 days for chernoembolization quoted-abovei it could be argued"that particle embolization is inferior to chernoembolization in terms of procedural safety and patient comfort. This study emphasizes the need for properly designed, prospective, randomized trials comparing the effect of different treatment modalities for unresectable liver tumors, including neuroendocrine metastases. Meanwhile, there seems to be no compelling evidence to prefer particle embolization over chernoembolization when treating hepatic neuroendocrine metastases. References 1. Brown KT, Koh BY, Brody LA, et al. Particle embolization of hepatic neuroendocrine metastases for control of pain and hormonal symptoms. JVIR 1999; 10:397-403. 2. Perry LJ, Stuart K, Stokes KR, et al. Hepatic arterial chemoembolization for metastatic neuroendocrine tumors. Surgery 1994; 116:lll-117. 3. Clouse ME, Perry LJ, Stuart K, Stokes KR. Hepatic arterial chernoembolization for metastatic neuroendocrine tumors. Digestion 1994; 55(suppl):92--97. 4. Gates J , Hartnell GG, Stuart K, Clouse ME. Chemoembolization of hepatic neoplasms: safety, complications and when to worry. Radiographics 1999; 19:399-414. 5. Hartnell GG, Gates J , Stuart K, Underhill J, Brophy DP. Hepatic chernoembolization: effect of intraarterial lidocaine on pain and other complications. Cardiovasc Intervent Radiol 1999; 22:293-297.
Effectiveness and Complications of Treating Neuroendocrine Metastases, Embolization versus Chemoembolization From: George G. Hartnell, FRCR Department of Radiology and Radiological Science Johns Hopkins University Hospital 600 Wolfe Street Blalock 546 Baltimore, Maryland 21287 Editor: Dr. Brown and her colleagues are to be congratulated on the results they report for treatment of hepatic neuroendocrine metastases by particle embolization (1).Although the results are clearly very good, a number of points made in their Discussion section require comment. One point concerns the issue of complications and duration of hospital stay when compared with treatment with chemoembolization as previously reported by Perry et a1 (2) and Clouse et a1 (3). Brown et al. state that, with better case selection, they would have achieved a lower complication rate than has been reported for chernoembolization.
This is not surprising-we could all improve our complication rates with the aid of retrospective patient selection. This applies as much to chernoembolization as any other embolization. However, Brown et a1 (1)report a patient mortality of 12% (4 of 35 patients) which seems to be significant compared with the zero mortality reported by Clouse et a1 (3) for chernoembolization of neuroendocrine metastases. Twelve percent mortality is also much higher than the overall 2% procedural mortality for a much larger group of chemoembolizations (251) for all tumor types, reported from the same institution (4). Another issue is that when discussing historic data as reported by Perry et a1 and Clouse et al, they are looking a t a moving target. The studies cited refer to experience including patients treated some years ago. In particular, the reported length of stay no longer represents what is expected of the best current practice. Working with Drs. Perry and Clouse in the same institution in 1996 and 1997, we were able to achieve much shorter average hospital stays. In the first quarter of 1996, the mean hospital stay for all patients undergoing chernoembolization was 67.5 hours, and for the first quarter of 1997, the mean length of hospital stay had been reduced to 53.5 hours. For chernoembolization of neuroendocrine metastases, mean length of hospital stay for the first quarter of 1997 was 46.7 hours (5). Brown et a1 rightly point out the limitations of their study, including the retrospective nature of the study. As they acknowledge, there was some lack of clarity about the outcomes of some embolizations, with incomplete data available. Therefore, although the results suggest that the longevity achieved by particle embolization may be an appropriate way of treating hepatic neuroendocrine metastases, the case is not as strong as they would suggest. Indeed, with their high mortalitv rate. com~aredwith that repoked elsewhere, and longer me& av&age hospital stay (5.6 days compared with the 2 days for chernoembolization quoted-abovei it could be argued"that particle embolization is inferior to chernoembolization in terms of procedural safety and patient comfort. This study emphasizes the need for properly designed, prospective, randomized trials comparing the effect of different treatment modalities for unresectable liver tumors, including neuroendocrine metastases. Meanwhile, there seems to be no compelling evidence to prefer particle embolization over chernoembolization when treating hepatic neuroendocrine metastases. References 1. Brown KT, Koh BY, Brody LA, et al. Particle embolization of hepatic neuroendocrine metastases for control of pain and hormonal symptoms. JVIR 1999; 10:397-403. 2. Perry LJ, Stuart K, Stokes KR, et al. Hepatic arterial chemoembolization for metastatic neuroendocrine tumors. Surgery 1994; 116:lll-117. 3. Clouse ME, Perry LJ, Stuart K, Stokes KR. Hepatic arterial chernoembolization for metastatic neuroendocrine tumors. Digestion 1994; 55(suppl):92--97. 4. Gates J , Hartnell GG, Stuart K, Clouse ME. Chemoembolization of hepatic neoplasms: safety, complications and when to worry. Radiographics 1999; 19:399-414. 5. Hartnell GG, Gates J , Stuart K, Underhill J, Brophy DP. Hepatic chernoembolization: effect of intraarterial lidocaine on pain and other complications. Cardiovasc Intervent Radiol 1999; 22:293-297.