The Centers for Disease Control and Prevention guidelines for the prevention of catheter-related bloodstream infections suggest using "a subclavian site, rather than an internal jugular or a femoral site, in adult patients." This recommendation is based on evidence of lower rates of thrombosis and catheter-related bloodstream infections in patients with subclavian central venous catheters (CVCs) compared to femoral or internal jugular sites. However, preference toward a subclavian approach to CVC insertion is hindered by increased risk of mechanical complications, especially pneumothorax, when compared to other sites. This is largely related to the proximity of the subclavian vein to the pleural space and the traditional "blind" or anatomic landmark approach used in subclavian vein cannulation. We revisit a method that may provide increased safety and avoidance of pneumothorax during ultrasound-guided subclavian/axillary vein cannulation. This is achieved by directing the needle toward the subclavian vein at a point where it traverses over the second rib, providing a protective rib shield between the vessel and pleura as a safety net for operators. The technique also allows for increased compressibility of the subclavian/axillary vein in the event of bleeding complication.

Objectives: To determine the feasibility of a combination of tracheal and thoracic ultrasonography to confirm adequate positioning of endotracheal tube placement in a cohort of critically ill patients. Design: Prospective, multicenter, observational study from January 2019 to May 2020. Setting: Multicenter study conducted in multiple ICUs across four different academic tertiary and community hospitals. Patients: Eligible patients were adults (≥ 18 yr) requiring endotracheal intubation and intensive care. Intervention: Tracheal and thoracic ultrasonography were performed during intubation attempts to rule out esophageal intubations, to detect mainstem intubations, and to confirm and adjust endotracheal tube position. Measurements and Main Results: Among 118 patients, median age was 66 years (interquartile range 56–73 yr), body mass index 28 (interquartile range 25–34), and 63.6 % were males. Using the ultrasound protocol, one esophageal (0.9%) and five main stem intubations (4.2%) were detected. 97.5% of final endotracheal tube positions confirmed by ultrasound were in concordance with the next occurring chest radiograph, with only three (2.5%) requiring minor post-chest radiograph adjustments. Conclusions: A protocolized, systematic approach using tracheal and thoracic ultrasonography can be used to confirm endotracheal intubation, detect main stem intubations, and guide tube positioning in the critically ill. This ultrasonographic approach is easily applicable, safe, and comparable to chest radiography. This approach may serve as a potential alternative or adjunct when chest radiography is not available or ideal. This has the potential to be used for routine intensive care, out-of-hospital or resource-poor settings, or situations which require isolation precautions to mitigate the use of chest radiography.

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In our patient, HSV was confined to the larynx, without evidence of local or systemic disease. Localized HSV laryngitis has been attributed to suppressed cellmediated immunity from HIV, chemotherapy, and prolonged corticosteroid use. In contrast, our patient was likely susceptible to HSV infection from damaged laryngeal mucosa from prior radiation exposure. Vrabec et al. noted the importance of maintaining a high index of suspicion of HSV laryngitis in patients who fail extubation, as was evident in this patient. Our case demonstrates that HSV can present at an atypical anatomic site and cause extensive damage, compromising airway patency if left untreated.Case Report: Spinocerebellar Ataxia Type 7 (SCA-7) is a pathological condition stemming from CAG repeat expansions. The CAG expansions induces propagation of the ataxin-7 protein, with subsequent rapid progression of multi-organ tissue infiltration. An increasing number of pathological repeats may represent prognostic indicators for patients; with larger repeats correlating with worse prognosis. We report a 2 month old female with global hypotonia, intermittent hypoxemia, and a family history notable for walking difficulty and visual impairment across multiple generations, consistent with autosomal dominant inheritance. Echocardiogram revealed a Patent Ductus Arteriosus (PDA); Catheterization demonstrated Coarctation of Aorta, type B as well as elevated trans-pulmonary gradient, responsive to oxygen and inhaled Nitric Oxide. The patient underwent end to end aortic anastomoses and PDA resection via lateral thoracotomy. Morbidity included chronic anasarca secondary to capillary leak syndrome; respiratory failure and inability to wean from ventilatory support due to global hypotonia necessitating tracheostomy; chronic renal failure with azotemia; concentric left ventricular hypertrophy-cardiomyopathy in the absence of residual aortic gradient; and visual evoke potentials consistent with blindness. DNA testing revealed a normal Karyotype (46,XX) and 78 CAG repeats of ataxin-7 gene protein.Repeats between 35 to 300 are known to be associated with pathology, while normal alleles contain 4 to 34 CAG units. The patient died within 3 mo of surgical repair; autopsy revealed septic pneumonia and cardiomyopathy as a cause of death. The longitudinal course of SCA-7 is unknown, as are the correlation between the repeat expansion sequences, clinical signs and symptoms, cardiomyopathy and neuropathology. Case reports of infantile SCA-7 suggests life expectancy of less than one year. Coarctation of Aorta has never been described in conjunction with SCA-7, making the post-operative course challenging when encountering multiorgan manifestations seen with this rarely described syndrome.

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