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Hospitalized children with underlying heart disease are at high risk for cardiac arrest, particularly when they undergo invasive catheterization procedures for diagnostic and therapeutic interventions. Outcomes for children experiencing cardiac arrest in the cardiac catheterization laboratory remain under-reported with few studies reporting survival beyond the catheterization laboratory. We aim to describe survival outcomes after cardiac arrest in the cardiac catheterization laboratory while identifying risk factors associated with hospital mortality after these events.Retrospective observational study of data from a multicenter cardiac arrest registry from November 2005 to November 2016. Cardiac arrest in the cardiac catheterization laboratory was defined as the need for chest compressions greater than or equal to 1 minute in the cardiac catheterization laboratory. Primary outcome was survival to discharge. Variables analyzed using generalized estimating equations for association with survival included age, illness category (surgical cardiac, medical cardiac), preexisting conditions, pharmacologic interventions, and event duration.American Heart Association's Get With the Guidelines-Resuscitation registry of in-hospital cardiac arrest.Consecutive patients less than 18 years old experiencing an index (i.e., first) cardiac arrest event reported to the Get With the Guidelines-Resuscitation.None.A total of 203 patients met definition of index cardiac arrest in the cardiac catheterization laboratory composed primarily of surgical and medical cardiac patients (54% and 41%, respectively). Children less than 1 year old comprised the majority of patients, 58% (117/203). Overall survival to hospital discharge was 69% (141/203). No differences in survival were observed between surgical and medical cardiac patients (p = 0.15). The majority of deaths (69%, 43/62) occurred in patients less than 1 year old. Bradycardia (with pulse) followed by pulseless electrical activity/asystole were the most common first documented rhythms observed (50% and 27%, respectively). Preexisting metabolic/electrolyte abnormalities (p = 0.02), need for vasoactive infusions (p = 0.03) prior to arrest, and use of calcium products (p = 0.005) were found to be significantly associated with lower rates of survival to discharge on multivariable regression.The majority of children experiencing cardiac arrest in the cardiac catheterization laboratory in this large multicenter registry analysis survived to hospital discharge, with no observable difference in outcomes between surgical and medical cardiac patients. Future investigations that focus on stratifying medical complexity in addition to procedural characteristics at the time of catheterization are needed to better identify risks for mortality after cardiac arrest in the cardiac catheterization laboratory.

The study was conducted to evaluate the effect of inhaler aromatherapy on invasive pain, procedure adherence, vital signs, and saturation during port catheter insertion among patients diagnosed with cancer. The study was conducted in a nonrandomized controlled trial. Sixty patients including 30 patients in the intervention group and 30 patients in the control group, who were subjected with the same local anesthetic protocol, were included in the study. Aromatic mixture prepared by diluting orange, chamomile, and lavender oil in 70 mL distilled water was inhaled by the intervention group during the procedure. The data of the study were collected by using questionnaire, vital follow-up form, and visual analog scale. The patients in the intervention and control groups were similar in terms of sociodemographic and disease characteristics (P.05). It was determined that inhaler aromatherapy applied to patients in the intervention group decreased pain experienced during the procedure and facilitated the procedure adherence (P.05); however, it did not affect vital signs and saturation (P.05). It can be recommended to administer inhaler aromatherapy with pharmacological therapies during catheterization procedure since it decreases invasive pain and facilitates the procedure adherence.

PURPOSE OF REVIEW Pulmonary vascular disease (PVD) complicates the course of many cardiovascular, pulmonary and other systemic diseases in children. The physiological sequelae (pulmonary hypertension and elevated pulmonary vascular resistance) can overwhelm the right ventricle and lead to circulatory collapse. Despite the common end-point, the preceding pathophysiology is complex and variable and requires a tailored approach to diagnosis and management. In this article, we will review the most recent evidence and explore an approach to current controversies in the diagnosis and management of common or challenging patient subgroups. RECENT FINDINGS New methods of interpreting data derived from echocardiography and cardiac magnetic resonance imaging may assist in risk stratification and response to therapy. In specific patient subgroups, standard pharmacological therapies to reduce right ventricle afterload may be overutilized, ineffective and in some cases harmful. In the patient failing pharmacological therapy, new and novel techniques are being explored including temporary extracorporeal mechanical circulatory support, pumpless lung assist devices and novel surgical and catheterization procedures. SUMMARY PVD is a diverse entity, and attention to the underlying pathophysiology is essential for appropriate management. Despite significant advances in our understanding, the majority of data comes from small uncontrolled studies and must be interpreted with caution.

Background: Arrhythmia and sudden cardiac decompensation (acute myocardial infarct or acute heart failure) are the most often causes of out-of-hospital cardiac arrest (OHCA). Emergency cardiac catheterization followed by coronary revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting surgery [CABG]) or valvular surgery is a lifesaving procedure. However, the result of this emergency room resuscitated OHCA patients underwent cardiac invasive procedure was not well defined before. Materials and Methods: One hundred and seventy (including 23 traumatic and stroke, etc.,) out of 705 OHCA patients were resuscitated and achieved a return of spontaneous circulation (ROSC) at Emergency Room of Chung Shan Medical University Hospital from January 1, 2011, to March 31, 2015. Only 23 (M/F = 25/8) out of 147 medically resuscitated OHCA patient with one or more cardiac risk factors were transferred for emergency cardiac catheterization (33/147). Thirty-one of them (31/33) underwent PCI (either balloon angioplasty or stent deployment) with coronary culprit stenotic lesions (>70%) of right coronary artery (15), left anterior descending artery (12), circumflex branch of left coronary artery (5), and left main coronary artery (1). One of the rest two patients with aortic valvular stenosis who underwent aortic valve replacement; and another with triple vessel disease of coronary artery received CABG. Results: All 33 patients (22.4%) survived the catheterization procedures and were sent to intensive care units. 31 patients were in comatose state and 24 eventually deceased due to cardiogenic shock (16), septic shock (4), ventricular tachycardia and ventricular fibrillation (2), hyperkalemia (1) and multiple organ failure (1). Nine patients (27.3%) survived to hospital discharge and were followed up at OPD periodically (1.3–43 months, mean 30.4 months). Four OHCA patients required extra-corporeal membrane oxygenation support, but only one out of four underwent PCI and survived. Conclusions: The resuscitated OHCA (ROSC) patients with any cardiac disease in the past should undergo emergency cardiac catheterization and possible intervention procedure with an acceptable result (survival to hospital discharge rate of 27.3%).

Children with congenital heart disease may require long-term central venous access for intensive care management; however, central venous access must also be preserved for future surgical and catheterization procedures. Transhepatic venous catheters may be an useful alternative. The objective of this study was to compare transhepatic venous catheters with traditional central venous catheters regarding complication rate and duration of catheter service.Retrospective review of 12 congenital heart disease patients from September 2013 to July 2015 who underwent placement of one or more transhepatic venous catheters.Single freestanding pediatric hospital located in the central United States.Pediatric patients with congenital heart disease who underwent placement of transhepatic venous catheter.Cohort's central venous catheter complication rates and duration of catheter service were compared with transhepatic venous catheter data.Twelve patients had a total of 19 transhepatic venous lines. Transhepatic venous lines had a significantly longer duration of service than central venous lines (p = 0.001). No difference between the two groups was found in the number of documented thrombi, thrombolytic burden, or catheter sites requiring wound care consultation. A higher frequency of infection in transhepatic venous lines versus central venous lines was found, isolated to four transhepatic venous lines that had a total of nine infections. All but one was successfully managed without catheter removal. The difference in the proportion of infections to catheters in transhepatic venous lines versus central venous lines was significant (p = 0.0001), but no difference in the rate of infection-related catheter removal was found.Without compromising future central venous access sites, transhepatic venous lines had superior duration of service without increased thrombosis, thrombolytic use, or insertion site complications relative to central venous lines. Transhepatic venous catheters had a higher infection rate, and further investigation into the etiology is warranted.

Objectives Prior studies have shown inaccuracies in pulse oximetry readings at saturations less than 85%; however, no large studies have evaluated new sensors marketed for these low saturations. This study's purpose was to evaluate two sensors with claims of improved accuracy in children with saturations less than 85%. Design Prospective observational study. Setting Single institution; cardiac catheterization laboratory, and operating room. Patients Fifty patients weighing 3-20 kg with baseline saturations less than 90% undergoing surgical or catheterization procedure. Measurements and main results Data collected included demographics, diagnosis, continuous saturations from three different pulse oximeters (Masimo LNCS [Masimo, Irvine, CA], Masimo Blue [Masimo], and Nellcor Max-I [Medtronic, Dublin, Ireland]) and up to four blood samples for co-oximetry as the gold-standard arterial oxygen saturation. Analysis included scatter plots, smoothed regression estimates of mean continuous saturation levels plotted against corresponding arterial oxygen saturation values, and Bland-Altman plots. Bland-Altman analysis indicated increasing levels of bias and variability for decreasing arterial oxygen saturation levels for all three sensors, with a statistically significant increase in mean difference observed for decreasing arterial oxygen saturation level. The Masimo Blue sensor had the lowest mean difference, SD and Bland-Altman limits in patients with saturations less than or equal to 85%. At saturation range of less than or equal to 85% and greater than 75%, 14% of the samples obtained from Masimo Blue, 24% of the readings from the Nellcor, and 31% from the Masimo Standard sensors were greater than or equal to 5% points difference. All three sensors had a further increase in these differences for arterial oxygen saturation values less than 75%. Conclusions The Masimo Blue sensor has improved accuracy at saturations 75-85% versus the Nellcor and Masimo Standard sensors. The accuracy of peripheral capillary oxygen saturation of the Masimo Blue sensor was within 5% points of the arterial oxygen saturation the majority of the time. Currently, at saturations less than or equal to 85%, pulse oximetry alone should not be relied on in making clinical decisions.

Fentanyl is a potent opiate commonly administered during cardiac catheterization procedures in North America.1 The question of whether fentanyl could have adverse consequences in patients undergoing percutaneous coronary intervention (PCI) is raised by recent research demonstrating that intravenous morphine significantly delays the absorption of oral P2Y12 platelet inhibitors.2 The presumed mechanism is slowed gastric emptying. The single-center PACIFY trial (Platelet Aggregation With Ticagrelor Inhibition and Fentanyl; ClinicalTrials.gov. Unique identifier: NCT02683707) randomized adults undergoing clinically indicated elective coronary angiography to receive the procedure with or without intravenous fentanyl.3 The study was approved by the Johns Hopkins Medicine Institutional Review Board, and all participants provided written informed consent. Eligible adults had not received P2Y12 inhibitors for 14 days before enrollment. Other exclusion criteria included preprocedural treatment with oral anticoagulants or opiates, platelet count

Background: Humans have lower risk for myocardial infarction and stroke at higher altitudes. The mechanism is unknown. We previously demonstrated that acute reductions in ambient air pressure result in enhanced arterial vasodilation ex vivo using a myograph model of murine resistance arteries. Enhanced vasodilation might increase effective arterial compliance in vivo , thus we further hypothesized a reduction in systemic vascular resistance in vivo as a result of lowered ambient air pressure. Methods: In-vivo Pressure Volume Loops: A novel hypobaric chamber was designed and constructed with the capacity to hold a single anaesthetized mouse and simulate a variety of lowered air pressures within the chamber. The design of the chamber allowed for monitoring of murine heart rate, respiratory rate, & blood oxygen saturation at all times. Using inhaled isoflurane to anesthetize the animal, a closed-chest left-ventricular catheterization procedure was performed within the chamber on free-breathing adult male C57-WT mice (n=8) during consecutive acute exposures to the three air pressure steps: 754 mmHg (control or room atmospheric pressure), 714 mmHg (p1) and 674 mmHg (p2). Results: In-vivo : Total systemic vascular resistance was reduced by acute exposure to lower air pressure (10.09±0.15 mmHg*min/μL at control vs. 8.11±1.45 and 8.18±1.24 mmHg*min/μL at p1 and p2, respectively; p Conclusion: Acute reductions in ambient air pressure lower systemic vascular resistance, and increase cardiac output and stroke volumes in vivo .

Over the past several decades, major changes in lifestyle, preventive care, and clinical management have contributed to an impressive reduction in coronary artery disease prevalence, incident acute myocardial infarction, and deaths due to coronary heart disease.1–3 As a result, the use of cardiovascular services in the United States has decreased dramatically in recent years. For patients with coronary artery disease, advances in medical management have allowed more and more patients to avoid elective catheterization procedures, whereas the results of recent studies (eg, Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE],4 Fractional Flow Reserve versus Angiography for Multivessel Evaluation [FAME],5 and Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery [SYNTAX]6) have led to the more judicious use of percutaneous coronary intervention (PCI) in patients with chronic coronary artery disease. The combined effect of these trends has been a marked reduction in overall PCI volumes,7 from a peak of nearly 1 million in the United States in 2006 to ≈600 000 in recent years.8 At the same time as overall PCI volumes have been decreasing, the number of PCI centers has been increasing as data have emerged indicating that the absence of on-site cardiac surgery does not adversely impact patient outcomes after either emergent or elective PCI.9,10 Together, declining PCI volumes and the increasing number of PCI centers has led to a decrease in the volume of PCI procedures at both the center and operator level.11 Articles see p 1383 and p 1392 Common sense dictates that any skill requires adequate experience to ensure optimal results. This holds true for airline pilots, hairdressers, and physicians alike. What differs among the professions is what qualifies as adequate experience. In his book Outliers , Malcolm Gladwell describes the “10 000 hour …

Purpose of review Despite progressive improvement in surgical results, hypoplastic left heart syndrome remains one of the congenital heart abnormalities with the greatest morbidity and mortality. Hybrid approaches to management, combining surgical and interventional catheterization procedures, have been introduced to minimize exposure to cardiopulmonary bypass, and improve outcomes for these high-risk infants. Recent findings First-stage palliation of hypoplastic left heart syndrome has been performed as a hybrid procedure combining surgical pulmonary artery banding with catheterization stenting of the ductus arteriosus and balloon atrial septostomy, especially in high-risk patients. Additionally, several centers have performed second-stage palliation – bidirectional Glenn or hemi-Fontan procedures – in a manner that allows the subsequent ‘Fontan’ procedure to be completed in the catheterization laboratory with a covered stent. Summary These innovative procedures offer the potential of an alternative management strategy for hypoplastic left heart syndrome. They have been applied to a very limited number of patients and long-term results are not available. Their role in management of hypoplastic left heart syndrome remains to be defined, especially as results of conventional surgical management continue to improve.

All patients would prefer to avoid a complication of a cardiac procedure—thus, discussion of risks of stroke, death, and bleeding resonate with patient-oriented decision-making processes. Contrast exposure may induce a transient decrease in renal function after cardiovascular catheterization procedures. Contrast-induced acute kidney injury (CI-AKI) has been clearly associated with worse cardiovascular outcomes at 1-year follow-up. But, it is difficult to discuss this complication with patients in a meaningful manner: a patient does not feel a creatinine rise of 25% occurring 48 hours after their procedure. Furthermore (1) the definition of CI-AKI is variable,1 (2) prevention strategies remain controversial,2,3 and most importantly (3) the connection between prevention of CI-AKI and improved long-term cardiovascular and renal outcomes is unproven.4 See Article by Wiegerinck et al In this issue of Circulation: Cardiovascular Interventions , Quintavalle et al5 provide an assessment of the inflammatory biomarker, neutrophil gelatinase–associated lipocalin (NGAL), as a measure of CI-AKI. NGAL is stored in neutrophil granules and is released in response to inflammation or ischemia: a rise in NGAL is not specific to kidney injury, and elevated NGAL levels have been associated with progression of coronary atherosclerosis and microvascular dysfunction.6 Furthermore, NGAL is not the only biomarker associated with increased risk of CI-AKI: a rising serum cystatin C and baseline levels of red cell distribution width also predict increased creatinine 48 hours after angiographic procedures.7,8 But, the authors present a convincing biomarker argument in this registry analyses of 458 high-risk patients: NGAL rises earlier (6 hours post contrast media exposure) than other biomarkers and can thus serve a prognostic role beyond baseline risk scores and other less rapidly rising markers in facilitating the definition and treatment of CI-AKI. In this study, both the development (n=458) and validation (n=253) sets of …

We determined what is important to feel good in daily life when living with a long-term illness that requires daily treatment routines.Seven boys between 6 and 16 years old who were born with posterior urethral valves narrated their experiences with daily life. They were on clean intermittent catheterization, had impaired renal function and 2 had undergone transplantation.Being involved in decisions about themselves was important, as was having their own doctor and nurse. Friends were important. Clean intermittent catheterization was something that worried them in relation to friends and made them feel uncertain about how they would react to it. The boys accepted the catheterization procedure as something that had to be done but they needed strategies to be able to comply. A single event, such as no available toilet, was enough to interrupt treatment.In these boys prescribed treatment was a surprisingly small part of their lives. The clean intermittent catheterization routine was sometimes experienced as an obstacle in company with friends. The new challenge might be to achieve compliance with the treatment routine in daily life in a long-term perspective.

Background: This is the first blinded, randomized, placebo-controlled clinical trial to evaluate the efficacy of poly-N-acetyl glucosamine (p-GLcNAc) in improving hemostasis in patients undergoing cardiac catheterization. Methods: Patients were randomly assigned to have either a placebo-treated (n = 17) or a p-GlcNAc-treated (n = 16) 3 x 3-cm patch topically placed at the femoral insertion site at the completion of their catheterization procedure with a mechanical pressure clamp applied over it. The amount of pressure was measured. Results: Although the placebo group had slightly higher clamp pressure applied to the femoral arterial puncture site at the end of the catheterization procedure (189 ± 47 vs. 149 ± 49 mm Hg,p = 0.042), the time to effective hemostasis (16 ± 7 vs. 10 ± 3 minutes, p = 0.01) was decreased in the p-GlcNAc group by 37%. Conclusion: The application of p-GlcNAc patches improved hemostasis at the arterial puncture site in patients undergoing cardiac catheterization.

Rationale Page kidney is an uncommon condition that hypertension occurs secondary to microvascular ischemia and alternation of small-vessel hemodynamics due to external compression of renal parenchyma and activation of the renin-angiotensin-aldosterone system. There are no specific guidelines for the management of Page kidney in the literatures. Patient concerns A 17-year-old teenager who had Fontan procedure for tricuspid and pulmonary atresia in early childhood suffered from sudden onset of severe left flank pain during cardiac catheterization procedure. Left renal artery active bleeding with renal parenchyma compression in association with renin-mediated hypertension led to the diagnosis of Page kidney. Diagnoses Page kidney was diagnosed in this case. Interventions Urgent embolization was performed to treat left renal artery active bleeding. Because of decreased renal function with elevation of serum creatinine, inadequate blood pressure control with antihypertensive medication, and poor renal blood flow of left kidney, open drainage of perirenal hematoma was done 5 days after catheterization procedure. Outcomes After the operation, glomerular filtration rate improved immediately, and left flank pain and hypertension resolved at discharge. Lessons The choice of the therapies for Page kidney depended on the clinical presentation of each case. This case pointed out the significance of renoscintigraphy and surgery in the management of Page kidney.

Congenital heart disease (CHD) is the most prevalent and fatal of all birth defects, occurring in nearly 1 in 100 live births.1 Before the advent of cardiac surgery for congenital cardiac malformations, less than one fifth of children born with such lesions reached adulthood. The progress of surgical management and, more recently, interventional catheterization has allowed an increasing number of congenital heart defects to be corrected surgically so that an increasing number of patients reach adolescence and adult life, even those with complex defects.2,3 Article see p 1903 Indeed, grown-up patients with surgically repaired CHD are a large and growing population, estimated to be 1 million in United States in the year 2000 compared with an estimated 300 000 in 1980, and 1.4 million cases are anticipated in 2020.2 Numbers are likely to be similar in the European Union, although no hard figures are available.3 One worrisome social and medical problem in the management of patients with CHD is certainly the long-term effects of intensive medical exposure to ionizing radiation received during childhood, especially for interventional catheterization procedures.4–7 Pediatric cardiac catheterizations are undoubtedly an essential diagnostic and therapeutic tool for the diagnosis and the treatment of CHD; however, they also deliver one of the highest radiation doses to patients.4–7 Ionizing radiation exposure is a definite risk factor for cancer development. Children are especially vulnerable to the oncogenic effects of radiation. Tissues and organs that are growing and developing are more sensitive to radiation effects than those that are fully mature. Moreover, the oncogenic effects of radiation require a long latent period (decades) that varies with the type of malignancy. Thus, an infant or child patient has a longer lifetime risk for developing radiation-induced cancers than adult patients.8 In addition, catheterization procedures are also …

Background Protamine is used to reverse the anticoagulant effects of heparin, but it can have important side effects. Platelet factor 4 (PF4) is a protein found in platelet alpha granules that binds to and thereby neutralizes heparin. We evaluated the safety and effectiveness of intravenous recombinant PF4 to neutralize heparin anticoagulation after cardiac catheterization in a phase 1, open-label trial. Methods and Results The study group consisted of 18 patients having diagnostic cardiac catheterization. Heparin (5000 U) was given after vascular access was obtained. In the first 12 patients, additional heparin was given at the conclusion of the procedure so that all patients had activated coagulation times >300 seconds before rPF4 was given. Three patients each received 0.5, 1.0, 2.5, or 5.0 mg/kg rPF4 over a period of 3 minutes at the conclusion of the catheterization procedure. In 6 additional patients, extra heparin was not given at the conclusion of the procedure, and 1.0 mg/kg rPF4 was given. Hemodynamic measurements, cardiac output, and serial blood tests were performed 5, 10, 20, and 30 minutes after rPF4 and then into the next 24 hours. There were no serious side effects in any patient, despite transient rPF4 levels as high as 14 870 ng/mL in the patients receiving 5.0 mg/kg. One patient receiving 2.5 mg/kg had a slight transient rise in liver enzymes possibly related to the rPF4. There were no important hemodynamic effects of rPF4 administration at any dose used. Doses of 2.5 and 5.0 mg/kg were uniformly effective in reversing the anticoagulant effect of heparin. At lower doses, rPF4 neutralized the effects of heparin in most but not all patients. Pharmacokinetic analysis suggested a monophasic and one-compartment clearance of the PF4-heparin complex. No neutralizing factors to rPF4 were detected in the samples collected 7 days after dosing. Conclusions rPF4, in doses ranging from 0.5 to 5.0 mg/kg over 3 minutes, had no serious side effects. Given in sufficient amounts, rPF4 can completely and rapidly reverse the anticoagulant effects of heparin.

Cardiac catheterization is a minimally invasive procedure commonly used to diagnose and treat heart conditions. During catheterization, small tubes (catheters) are inserted into the circulatory system under x-ray guidance in order to obtain information about blood flow and pressures within the heart and to determine if there are obstructions within the blood vessels feeding the heart muscle (coronary arteries). Obstructions of the arteries are caused by plaque buildup, and when severe they can cause a variety of symptoms including chest pain and shortness of breath. A catheterization may be recommended on an elective basis if the symptoms are stable or on an emergency basis if the symptoms are sudden and the treating physician is concerned that they may represent an active or impending heart attack. On the basis of the location and number of obstructions, the treatment plan will include the use of specialized medications and possibly the placement of a stent or referral for bypass surgery to improve blood flow to the heart muscle and alleviate symptoms. The catheters necessary for cardiac catheterization can be inserted either into the femoral artery (in the groin), or into the radial artery (in the wrist). The femoral artery is a larger vessel and provides a more direct route to the heart. Because of these advantages, the femoral artery has become the standard entry site for catheterization procedures. However, there has been a recent increase in …

The placement of percutaneous peritoneal dialysis catheters under direct peritoneoscopic visualization is a relatively new technique for establishing peritoneal dialysis access. In this study, in which a modification of the Seldinger technique was used to facilitate the placement of the peritoneoscope, the experience with 82 consecutive catheterization procedures in 78 patients is reported. In 2 (2.4%) of 82 catheterization procedures, we were unable to enter the peritoneal cavity but experienced no other complications unique to the percutaneous approach. Of the 80 successful catheterization procedures, 76 represented first-time catheter placement and constituted a population subjected to life-table analysis examining catheter survival rates, the time to first cutaneous exit site or s.c. tunnel infection, and the time to first episode of peritonitis. After a follow-up period of 50.1 patient yr, 11 catheters were lost because of catheter dysfunction. Other clinical complications included peritoneal fluid leaks at the cutaneous exit site in 11 instances (0.22/patient yr), cutaneous exit site infection in 7 instances (0.14/patient yr), s.c. tunnel infection in 2 instances (0.04/patient yr), and 34 episodes of peritonitis (0.68/patient yr). The results of this study demonstrate that the suggested modification of the percutaneous placement of peritoneal dialysis catheters, under peritoneoscopic visualization, is a viable method for establishing peritoneal access.

Jugular bulb catheterization (JBC) provides cerebral venous access for titration of brain-specific therapy. Little has been written about the catheterization procedure. We prospectively studied the time, number of punctures, success rate, and complications during JBC for a 24-month period in our ICUs. One hundred twenty-three patients (mean age 6.7 yr, range 12 hours to 21 yr) underwent JBC. Procedure time was 15.6 +/- 5.0 (SD) min. Median number of skin punctures was two. All but four were successful on first attempt. Three of the remaining were catheterized on second attempt. Inadvertent carotid puncture occurred in 3%. No other significant complications were noted. Radiography confirmed proper position in 97%. Duration of indwelling venous catheters was 2.5 +/- 1.6 days. All catheters functioned well until removal. We conclude that our technique of JBC is safe and highly successful. It compares favorably with previous, smaller series and with standard anterograde internal jugular catheterization in both children and adults.

A reflection cuvette oximeter providing instantaneous values has been used in a series of 195 cardiac catheterizations in infants and children. The introduction of this method had considerable influence on the entire catheterization procedure, since the direct availability of fluoroscopic, pressure, and oxygen saturation data allows development of an accurate and complete diagnosis during the catheterization. Six cases, selected because of the important part direct oximetry played in their elucidation, are discussed.