vascular access service - opi pavia · vascular access devices vascular access everywhere more than...
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Vascular Access Service
Our story so far Dott.ssa Alessandra Palo
Direttore AAT Pavia - SAV
Dipartimento Medicina Intensiva
Fondazione IRCCS San Matteo Pavia
More and more
patients with
chronic illness
Vascular
access
devices
Vascular access everywhere
More than 5 millions of CVCs inserted every year
Our origins
Our hospital specialized in OncoEmatology and
organ transplantation
This led to a strong demand of advanced vascular
access devices
Our origins
This challenge was taken up by Dr.Bellinzona
(anesthesiology and critical care), Dr.Albertario
(surgery and critical care) and Dr.Serafini
(pediatric anesthesiology) in the ‘80s
The first implants (Groshong and Broviac) were
done in OR and radiological suite
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2013 2014 2015 2016 2017
Procedures
Procedures
Our areas of expertise
360° vascular access
Totally US-guided
X-ray free
Outpatient-centered
H24 mobile phone (calls, SMSs and WhatsApp)
360° vascular access =
SAV
Selection
Insertion
Management
Complications
Counselling
Training
360° vascular access =
SAV
Adult and pediatric
CICC
PICC
MIDLINE
PORT
Tunnelled
and dialysis-tunnelled
devices
Totally Implantable
Vascular Access Devices
360° vascular access =
SAV
Adult and pediatric
Experts
Residents
Trainees
Consultants
Visiting physician
Nurses
DEVICE CHOISE
• CVC short term (CICC)
• CVC long term (> 30 days)
INFORMED CONSENT
LONG TERM CVC
• Dialysis and apheresis
• High-flow catheters
• Tunneled short & long-term
• Drug-linked patency
• Jugular or femoral access
LONG TERM CVC
• Tunnelled catheters
• Exit-site far from puncture site – mostly sub-cutaneous
• Lower infection complications
• Difficult and complex insertion and removal
• Totally implanted catheter (Port)
• Surgical insertion and removal
• Catheter life
• Very low infection complications
LONG-TERM CVC
• PICC
• Less complications than CICC
• More infectious complication than tunneled devices
• Thrombosis ? - Mispositioning – Slow flow
• Less in-site span than tunneled and totally implanted devices
• New role in intensive and surgical settings
SHORT/LONG-TERM CVC
Antiseptic or antimicrobial coated CVC • Antiseptic agents (chlorhexidine-sulfadiazine)
• Antimicrobial agents (minocycline-rifampicin)
• SETTINGS
• Operating Units or patients with CRBSI frequency above institutional objective despite of basal prevention procedures
• Patients with poor venous asset and history of recurrent CRBSI, patients with higher risk of serious consequences in case of CRBSI
VEIN CHOICE
• PICC (basilic-brachial-cephalic vein)
• CICC
• Dialysis
• Femoral vein for urgency vascular access
• Subclavian vein blind-access 1° choice subclavian vein echoguided
• Right jugular vein elective for dialysis/apheresis
CVC
CICC
Centrally Inserted
Central Catheter
PICC
Peripherally Inserted
Central Catheter
Same insertion
CVC NOT a CVC
Midline vs. PICC
PVC
MiniMidline
Midline
PICC
Not C
VC
C
VC
PICC
Peripherally
Inserted
Central
Catheter
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200
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400
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600
2014 2015 2016 2017
PICC
PICC
PICC-Related Thrombosis
Big catheters in small veins
It is considered the most important
issue related to PICCs
Not well known
PICC-RT
The first real-world study to describe early onset PICC-RT
Weekly US screening
Recruiting, stop 31st Dec 2017, n=300
Insertion • Effectiveness
• Safety
Total US-guide
Always RACEVA/RAPEVA
Choose the right vein/the right side)
Simulate during LA
Always check the guidewire before dilation
SAV insertion bundle
Tip-navigation and -confirmation: best performance/complications
Bubble-test: check iv position
From blindess to ultrasounds
Always use US
Always perform RACEVA
RApid Central Vein Assessment
It’s similar to the old concept of “static” ultrasound
guidance (i.e. to take a look before puncture)
http://www.officialpsds.com/
Neck-High
Neck-Low
Neck-Lateral
Ax SX
Ax LX
Always perform RAPEVA
RApid PEripheral Vein Assessment
It’s similar to the old concept of “static” ultrasound
guidance (i.e. to take a look before puncture)
1. Cephalic v. at elbow
2. Brachial a . and vv. at
elbow
3. Basilic v. upward
4. Vascular nerve bundle
(brachial a.+vv.
+median nerve)
5. Cephalic v.
6. Axillary v.
7. Supraclavicular
subclavian v.+ internal
jugular v. + innominate
v.
What to look at during RACEVA/RAPEVA
Is there the vein?
Anatomical relations?
Thrombosis?
Diameter!!!
Depth
Vein: CVC ratio 2:1 minimum
3:1 best
Guidewire verification
It’s a very important step
You must always check the intravenous position of
your guidewire before dilation
Failure to check can result in serious mechanical
complications
SAV Pavia 2016 (N~1000)
RIJV Others
0.0% failure 0.0% complications
TIP POSITION
WHY IS TIP POSITION SIGNIFICANT?
FAR FROM THE HEART
• Low flow
• Stenosis
• Perforation
IN THE HEART
• Malfunction
• Perforation
• Arrhythmias
CLOSE TO
THE HEART
• High flow
• No trauma
“Confirm the final
position of the
catheter tip as soon
as clinically
appropriate.”
ECG
CEUS
Fluoroscopy
RX
Wikidoc.org
1989
1998
2010
2009
TIM
E
• LCT has disappeared from
Literature
• No cases from 2000
Place the tip of CVC
outside of the atrium
So do we have to choose the right tip position
because there is a risk of cardiac perforation?
No
we must choose the position with less
complications and best performance
Best tip position In a vein as large as possible
Parallel to its long axis (no
zone B from the left)
Out of pericardial sac???
Low SVC-High RA
High SVC: not for a long time
Low RA-RV: pull back
Far from
SVC/RA
junction
=
More
thrombosis
and
malfunction
Distal RA
=
Arrhythmias
2 cm
Breathing
Arm movements
Body posture
Infusion flow
The CAJ is the safest site
2 cm up: still in the lower SVC
2 cm down: still in the upper RA
Chest-RX interpretation is
inconstant
ULTRASOUND
Tip position and anesthesia
BUT you have to check the intravenous position of the
CVC/guidewire before starting the operation
Check the intravascular
position of the needle
Check the intravenous
position of the guidewire
Check the functionality of
the catheter
Post-op tip position
confirmation
Flush test!
The flush test
It’s a very useful test to confirm intravenous position of the tip
CEUS patterns Negative test (=incorrect tip position)
No bubbles: caution non-intravenous tip!
Laminar flow>2 sec: misplacement
Immediate turbulent flow: RA
Positive test (=correct tip position)
Laminar flow<2 sec
CEUS limitations
2 skilled operators needed
Cardiologic probe
Subjective (learning curve)
Tricky to document
RX free
Written protocol
Tip navigation
Significant primary malposition rate of
PICC and CICCs (not from RJV) is 10-30%
Tracking
Location
Real time
tracking of
device direction
in comparison to
the heart
To avoid primary
malposition
Actual and
precise tip
position in
comparison to the
heart
Less complications
and optimal
function
NAVIGATION: intraprocedural method by
definition
Fluoroscopy
Ecography
Electromagnetic tracking
US are extremely useful but their role in tip location is
still controversial
Tracking systems
Cathfinder
Navigator
Sherlock Vasonova (Arrow VPS G4)
Electromagnetic
tracking
iECG
confirmation
+
Is the post-procedural chest X-ray sufficient? No
Precise or not…
…it’s not intra-procedural
Immediate use
Intravenous position
Bubble tests
Long-term use
Precise tip position
iEKG
US are extremely useful but
can’t be used to exactly
locate the tip of our devices
iEKG
BBraun
The tip of the device is used
as an intracavitary moving
lead electrode
Anatomical basic: SAN is the
most accurate marker of CAJ
S-A node
A-V node
http://www.hektoeninternational.org/
The CVC tip becomes the negative terminal of lead II
iEKG techniques
Metallic guidewire vs. fluid column
Home-made vs. ad-hoc
Adaptors vs. iEKG dedicated equipments
Cavo rosso (o verde)
Derivazione D2
Requisiti onda P
Applicability 90-95%
99.3% Patients with no visible P wave at the
standard baseline ECG were exclude
Still in use
today!
Pediatric access
A real problem Children’s veins are
smaller
Often no suitable kit is
available
The best sets are the ones in
PICCs trays
Real-time ultrasound techniques
(anatomy, puncture, navigation,
localization….) have their greatest
usefulness in pediatrics and are also
easier
Smaller probes
Sovraclavear approach to the innominate vein in the newborn
Tunneling in pediatrics
Tunneling can
address the lack of dedicated catheters
Correct tip location is vital in children
Management
Bundle CDC In
sert
ion
Mana
gem
ent
SAV management bundle 1 Strict hand hygene, before and after
2 Always alcoholic Clorexidine
3 Daily exit-site evaluation (VES)
4 Change dressing only when indicated (7 days)
5 Use the correct dressing (semi-permeable)
6 Use the right connector (not valved or MaxZero)
7 Disinfect connectors for 10 seconds with alcoholic Clorexidine
8 Change the lines only when indicated (minimum 96 hs)
9 Clean devices regularly and appropriately with pulsed saline
10 Daily assessment of the usefulness of devices
Ethanol lock
Biofilm “…a microbially derived sessile community
characterized by cells that are irreversibly
attached to a substratum or interface or to
each other, are embedded in a matrix of
extracellular polymeric substances that they
have produced, and exhibit an altered
phenotype with respect to growth rate and
gene transcription.”
Antibiotics and biofilm
Organism Antibiotic MIC or MBC
(mcg/mL)
MIC in biofilm
(mcg/mL)
S. aureus
(NCTC 8325-4) Vancomycin 2 (MBC) 20
P. aeruginosa (ATCC
27853) Imipenem 1 (MIC) >1,024
E. coli
(ATCC 25922) Ampicillin 2 (MIC) 512
P. pseudomallei Ceftazidime 8 (MBC) 800
S. sanguis Doxycycline 0.063 (MIC) 3.15
Donlan RM, Clin Microbiol Rev. 2002
Antimicrobial lock
Antibiotics
Vancomycin
Gentamycin
Cefazoline
Cefotaxime
Ciprofloxacin
…
Non antibiotics
Citrate
Taurolidine
Urokinase (B-I)
…
Ethanol
Ethanol lock
Extremely high concentration Extremely low
dose
High
efficacy No side
effects
NCT01186172
Ethanol Lock for the Salvage of Infected Long-term
Vascular Access
Unsuccessful for failed randomization (after the first cases, all the
physicians wanted only the Ethanol instead of the antibiotic!)