selected reports Preliminary Results of Bedside Inferior Vena Cava Filter Placement* Safe and Cost-Effective Ronald F. Sing, DO; Charles H. Smith, MD; William S. Miles, MD; and W. joseph Messick, MD
The use of inferior vena cava filters (IVCFs) is increasing in patients at high risk for venous thromboembolism; however, there is considerable controversy related to their cost. We inserted eight percutaneous IVCFs at the bedside. The hospital charges for bedside IVCF insertion were substantially lower compared with those for IVCF insertion performed in the Radiology Department or operating room. There was one death (unrelated to the procedure) and one asymptomatic caval occlusion believed to be caused by thrombus trapping. Bedside IVCF insertion is safe and costeffective in selected patients. This practice averts the potential complications associated with transporting critically ill patients. (CHEST 1998; 114:315-316) Key words: cost-effective; thromboembolism; vena cava filter Abbreviations: DVT=deep venous thrombosis; IVCF=inferior vena cava filter
Thromboembolic complications are significant contributors to morbidity and mortality in the trauma population. Prophylaxis using pneumatic compression devices or subcutaneous heparin is not always feasible in the multiply injured patient, and when deep venous thrombo-
For editorial comment see page 9 sis (DVT) or pulmonary embolism occurs, therapeutic anticoagulation often is contraindicated. Although inferior vena cava filte rs (IVCFs) are indicated for DVT pulmonary em holism or both with a contraindication to *From the Department of Surgery, Carolinas Medical Center, Charlotte, NC . Manuscript received July 11, 1997; revision accepted November 12, 1997. Reprint requests: Ronald F. Sing, DO, Department of Surgen;l MEB-601, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203
the rape utic anticoagulation, prophylactic (IVCF) placement in trauma patients is increasing. 1 • 4 There remains, however, considerable controversy over their use because of concerns for cost. 2 Ove r the past 12 months , IVCFs have been inserted at the bedside in selected patients in the (ICU). TECHNIQUE Patients were prepared with a povidone-iodine solution and draped with use of sterile drapes. The ICU beds were fluoroscopy-ready and, the refore , the patients did not re quire transfer to a specialized stretcher or unit. All procedures were performed by surgeons who were wearing sterile gowns and gloves with caps and fac e masks. B edside fluoro scopy was perform ed (perpendicular to the patie nt to avoid parallax) to identify th e 12 thoracic vertebra (T-12), and surface markers were placed on the patient to identify lumbar vertebrae. Fluoroscopy also was used in guidewire placement, insertion of introducer catheters, contrast venacavography, and deployment of th e IVCF. Two radiopaque markers were placed on the patient 28 mm apart for sizing of the inferior vena cava during the contrast venacavogram. The preferred approach was th e right internal jugular vein unless there was a contraindication (ie, existing central venous catheter or injury). Using the Seldinger technique, a 140-cm long, 0.038-i.nch-diarneter flexi ble guidewire was advanced into the vena cava. A small skin incision was then made with a No. 11 scalpel to allow for the subsequent dilator and introducer catheter. These catheters were first flushed with heparinized saline solution (10 units of unfractionated h eparin per l mL of normal saline solution). The dilator and introducing catheter also were inserted with the use of fluoros copy. The dilator was removed, and the introducer catheter was positioned at the level of the T-12 when using the internal jugular approach or L-5 when using the femoral approach. A hand-injected venacavogram was perform ed using 60 mL of intravenous contrast medium. Images were saved for a permanent reco rd. Anomalies, vena cava size, and th e location of the renal veins were determined. The introducer catheter again was flushed with heparinized saline solution, and the filter was advanced into the introducer catheter. All filters were then inserted into the infrarenal position, and their placement was confirmed by an abdominal x-ray film. Vena cava filters (Greenfield filt ers; Medi-Tech; Watertown, Mass ) were placed in the inferior vena cava 28 mm or less. Patients with infe1ior vena cava greater than 28 mm received a different vena cava filter (Bird's Nest filter; Cook Critical Care; Bloomington, Ind). The introducer catheter was removed, and direct pressure to the percutaneous insertion site was applied for 10 min. RESULTS
Eight IVCFs were successfully inserted percutaneously at the bedside in the ICU with the use of fluoroscopy (six Greenfield filters and two Bird's Nest filters) . Indications for insertion of IVCF in these patients are listed in Table l. Two filters were theraCHEST I 114 I 1 I JULY, 1998
Table !-Patient Demographics Patient Age (yr)/ No. Sex 61/M 2
4 5 6
19/M 31/M 84/M
Indications for IVCF DVf with contraindication to anticoagulation
(complex pelvic fracture) Complex pelvic fracture; lower extremity fracture; prolonged immobilization Complex pelvic fracture; lower extremity fracture; subarachnoid hemorrhage T-6 spinal cord injury with paraplegia C-6 spinal cord injury with quadriplegia Pelvic fracture; lower extremity fracture; history of pulmonary embolism Dvr \vith contraindication to anticoagulation (complex pelvic fracture) Pelvic fracture; subarachnoid hemorrhage; cerebral contusion
peutically placed for above-the-knee DVT and a contraindication to therapeutic anticoagulation. Six filters were placed for prophylaxis in high-risk patients. Ionic contrast was used in seven patients and nonionic contrast in one patient with renal insufficiency. One procedural mishap occurred-an inability to pass a guidewire through the internal jugular vein necessitating placement via a right femoral approach (successful). All filters were positioned correctly at the appropriate location and docume nted by abdominal roentgenogram . One death occurred 3 weeks postprocedure 2 weeks after the patient had been discharged from the hospital. An autopsy revealed the death to be caused by an acute myocardial infarction; the patient had severe, three-vessel coronary artery disease. Notably, he had an asymptomatic occlusion of the inferior vena cava to the level of the filter with thrombus extending to the pelvic veins located at the pelvic fracture site. We believe this was caused by the trapping of thrombus by the filter.
In this era of cost containment, many common practices in health care are being examined . It has been dogma that IVCFs be inserted either in the operating room or in the Radiology Department. The capability for percutaneous placement of IVCFs with use of the Seldinger technique has been available since 1984. 5 Prior to this, the introducer mechanisms were large (24F) and required surgical exposure of the femoral or internal jugular veins for insertion . The technique for percutaneous insertion of IVCFs is identical, whether performed in the Radiology Departme nt, operating room, or at the bedside; therefore, complication rates should be the same no matter where the procedure is pe rformed. Cost is , therefore, lower because there is no need for operating room setup, anesthesia charges, recovety room observation, transportation , and specialized angiography technicians and equipment. Six of the eight patients in this series were intubated 316
and required mechanical ventilation. Mishaps occurring during the transport of critically ill patients can lead to serious complications and death. 6 In patients not requiring transport for other studies, (ie, pulmonary arteriography), the potential mishaps of transport are averted. Radiation exposure to medical pe rsonnel and surrounding patients is minimized by attention to the three cardinal rules of radiation protection: time, shielding, and distance. Medical personnel directly involved in the procedure are required to wear lead shielding (torso aprons and thyroid shields ). Total fluoroscopy time for the entire procedure is less than 2 min (advancement of guidewire, contrast venacavogram, and insertion of the filter). Th e fluoroscope emits 1 to 2 R/min. Exposure (pe rpendicular to the beam ) at 0.5 m from the beam is 60 milliroentgen equivalent man (m REM )/h; at 1 m , approximately 5 mREM/h; and at 2 m, 0.9 to 0.4 mREM/h. 7 The beds in the ICU are at least 3 m apart. Normal background radiation over 1 year's time is 100 mREM; therefore, exposure is negligible.
Percutaneous placement of IVCF at the bedside was safe and cost-effective in this series. The avoidance of transporting critically ill patients to perform this procedure outside the ICU averts the potential complications that can occur during transport. A larger, prospective study of bedside IVCF placement is needed to confirm its benefits. ACKNOWLEDGMENT: The authors express their appreciation for the assistance of Richard E. McKeown, MS (Radiation Safety Officer at th e Carolinas Medical Center) in the preparation of this manuscript.
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