HIGHLIGHTS Ultrasound shows several venous changes in pediatric PIV-containing veins. Changes were visualized by ultrasound in the absence of physical exam findings. Venous luminal narrowing, wall thickening, and thrombosis may explain PIV failure. Background: Peripheral intravenous catheters (PIVs) are routinely used for venous access in hospitalized pediatric patients to administer fluids and medications and to aspirate blood. Unfortunately, PIVs do not remain functional for the entire duration of intravascular need. We hypothesized that PIV malfunction may be related to venous changes that can be visualized with ultrasound (US) imaging. The purpose of this study was to describe and document such changes in pediatric patients. Methods: This Institutional Review Board-approved study was performed at a tertiary pediatric medical center. Patients underwent US scans of their PIV-containing veins, documenting venous characteristics such as depth, diameter, wall thickness, blood flow, valves, branch points, and presence of thrombus. Patient demographics and PIV characteristics were also recorded. Results: Data from 30 patients including 12 males and 18 females with a mean age of 11 years were analyzed. Mean venous depth and diameter were 2.07 ± 0.13 and 2.02 ± 0.18 mm, respectively. Mean PIV dwell time at time of evaluation was 3.3 days. PIV-associated venous changes were seen in 73% of accessed veins and included lumen narrowing (47%), wall thickening (33%), presence of thrombus (20%), and absence of blood flow around the PIV tip (40%). Conclusion: PIV-associated venous changes are seen with US in the majority of pediatric patients with indwelling PIVs but are not necessarily appreciated on physical exam. These changes may help explain the high rate of pediatric PIV device failure. Given the small sample size, further investigation is needed to better characterize PIV-associated venous changes in children.
Highlights Ultrasound shows several venous changes in pediatric PIV-containing veins. Changes were visualized by ultrasound in the absence of physical exam findings. Venous luminal narrowing, wall thickening, and thrombosis may explain PIV failure.
Establishing venous access can be an important and often complex aspect of care for pediatric patients. When stable central venous access is required for long-term intravenous infusions, several options are available including peripherally inserted central catheters (PICC), tunneled catheters and ports. Both PICC placement and tunneled catheter placement include an exposed external segment of catheter, either in an extremity or on the chest. We present a pediatric patient with complex behavioral history who required long-term intravenous therapy. After careful review, the best option for the patient was determined to be a tunneled catheter that exited the skin in the right upper back, making it difficult to grab and pull out. The catheter was successfully placed and the patient appropriately completed his intravenous antibiotic course. Upon completion, the catheter was removed without complications. This tunneling technique to the scapular region may be useful for patients with psychiatric or neurodegenerative disorders where purposeful dislodgement may be a problem.
Introduction: Hypothyroidism is a common endocrine disorder with multi-system involvement, with prevalence rate of 4.6% among the U.S. population. Clinical manifestations of hypothyroidism can vary widely from subclinical condition to multi-organ failure. One of the rare but serious complications of hypothyroidism is pericardial effusion (PE). To our knowledge, there are few case reports of PE secondary to hypothyroidism. We report a case of massive PE without tamponade secondary to hypothyroidism. Case Presentation: 52 year old obese male presented to the hospital with worsening dyspnea, dry cough, chest discomfort and lower extremity edema for 2 months. He was in mild respiratory distress, and afebrile. He had myxedematous facies, with dry skin. Thyroid gland was palpable. He was noted to have distant heart sounds and bradycardia with lower extremity edema and delayed deep tendon reflexes. Chest X-ray showed marked cardiomegaly suggestive of pericardial effusion. Laboratory testing was noted for elevated thyroid stimulating Hormone 55.9 mU/L, Low T4F <0.07 mU/L, low T3F 1.0 mU/L, and elevated Thyroid peroxidase antibodies of 520 IU/ml. Troponin-I, BNP, and D-Dimer were normal. Echocardiography showed left ventricular ejection fraction of 50%, and a large, free-flowing pericardial effusion >2 cm with focal strands. Patient was given intravenous Levothyroxine 100 mcg once, then was started on oral Levothyroxine 75 mcg daily. No pericardiocentesis was done. Patient was discharged and followed up after 6 month of treatment with resolution of his symptoms, facies, and pericardial effusion. Discussion: Hypothyroidism is predominant worldwide with reported prevalence rates of 5–10% in women and 1–3% in men. Common symptoms include: fatigue, cold intolerance, and constipation. Cardiovascular involvement is less common. Small PE has been reported in 10-30% of cases. Severe PE -with or without tamponade- is a very rare complication and is only linked to severe degrees of myxedema. A recent study evaluating 70 newly diagnosed adult hypothyroid patients showed mild PE prevalence of 17%, with moderate PE seen in only 1 patient (0.01%). Severe PE or tamponade was not observed in this cohort. The development of PE secondary to hypothyroidism is not well understood. Increased systemic capillary permeability and decreased lymphatic drainage of albumin which leads to increased pericardial colloid pressure are proposed mechanisms for hypothyroid PE. Most of hypothyroidism clinical symptoms can be reversed with thyroid hormone replacement within 1-15 months. Pericardiocentesis is reserved for symptomatic patients despite treatment, patients with tamponade or with persistent PE for more than 3 months. Our case sheds light on a rare, yet, serious complication of hypothyroidism, most likely explained by low socio-economic status. Hence the importance of patient education and proper follow up.
Usage of vaping and electronic cigarettes products is a growing trend among young adults, with rising rates worldwide. Such products are gaining popularity for many reasons including an alternative to smoking cigarettes, trying something new, or as a means to relax. While users may feel that these products are less harmful or a safer substitute to smoking traditional products, the side effect profile of vape inhalation has the potential for profound injury to the lung tissue and significant respiratory failure. We would like to present a case in which a young male who was evaluated at our Emergency department for acute onset respiratory failure subsequently requiring invasive mechanical ventilation in the setting of vaping associated lung injury (VALI). In the case report, we will highlight the patient’s clinical course as well as a summary of the current evidence surrounding evaluation, diagnosis and management of this emerging pathology. We want to emphasize the importance of a detailed history which should include the use of vaping products when a young patient presents with acute respiratory failure, allowing VALI to be in the differential diagnosis. Additionally, we want to compare the clinical presentation of VALI to that of COVID-19 pneumonia as they both have many similar attributes including symptoms and findings on lung imaging studies.
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