PICCING The Right Vessel

Transcription

1 PICCING The Right Vessel Evan Alexandrou RN MPH PhD Clinical Nurse Consultant, Central Venous Access Service Liverpool Hospital Senior Lecturer Western Sydney University

2 Disclosures AVATAR research is supported by competitive government, university, hospital and professional organisation research grants as well as industry unrestricted donations, investigator initiated research/educational grants and occasional consultancy payments from the following companies: 3M, Adhezion, Angiodynamics, Bard, Baxter, BBraun, BD, Carefusion, Centurion, Cook, Entrotech, Flomedical, Hospira, Mayo, Medtronic, ResQDevices, Smiths, Teleflex, Vygon This presentation is independently prepared and reflects no commercial entity nor promotes particular products unless these are supported by research data Sources of funding for each particular research study will be disclosed throughout this presentation PRNewswire. (2014). Global Peripheral I.V. Catheter Market from html Alexandrou, Evan, Ramjan, Lucie, Murphy, Jeff, Hunt, Leanne, Betihavas, Vasiliki, & Frost, Steven A. (2012). Training of Undergraduate Clinicians in Vascular Access: An Integrative Review. Journal of the Association for Vascular Access, 17(3),

3 Background Peripherally Inserted Central Catheter (PICC) use has increased significantly since their introduction in the 1970s Initially used as an alternative to tunnelled long term central lines Millions now inserted globally every year Tens of thousands of PICCs inserted in Australia every year AIHW, Australian Hospital Statistics AIHW: Canberra idata Market Research Research 2014 Sandrucci, S., & Mussa, B. (Eds.). (2014). Peripherally Inserted Central Venous Catheters. Springer Milan.

4 Background PICCs have become popular because Can be used for hydration, TPN, antibiotics and medications not suitable for peripheral administration Great alternative for patients with limited access requiring prolonged IV Therapy Over half of all PIVCs fail prematurely - requiring reinsertion (cost: $35 $45) Sandrucci, S., & Mussa, B. (Eds.). (2014). Peripherally Inserted Central Venous Catheters. Springer Milan. Tuffaha HW, Rickard CM, Webster J, et al. Cost-effectiveness analysis of clinically indicated versus routine replacement of peripheral intravenous catheters. Applied health economics and health policy 2014; 12(1): 51-8.

5 PICCs can be safer to insert and manage.. PICC Arterial puncture Nerve injury Insertion related thrombosis Malposition More relaxed coagulation profile Post Insertion Phlebitis / Infection UEDVT Occlusion Accidental Removal CVC Arterial puncture Haemothorax Pneumothorax Nerve injury Tighter coagulation profile Post Insertion Infection Thrombosis Occlusion Accidental Removal air embolism

6 Device choice should be based on patient assessment The RIGHT trained clinician (credentialed, has procedural load) inserts The RIGHT device (length of dwell, infusate characteristics) into The RIGHT vessel (after vascular assessment) for. The RIGHT patient (clinical assessment, allergies, coags, GFR etc.) at The Right time (early intervention for timely treatment)

7 PICCs are not for everyone Small brachial veins Tortuous vessel pathway Previous thrombosis Preservation of fistula Mastectomy / lymph node dissection Fractures / contractures Venous depletion from chronic and complex disease

8 PICCs are not for everyone Vessel Diameter is Important 50% reduction in vessel radius = 94% reduction in blood flow Number of studies have found no more than a third of internal diameter of vessel should be taken up by catheter Vessel anatomy Vessel diameter Catheter gauge Easy way to remember: 3F PICC = 3mm vessel diameter 4F PICC = 4mm vessel diameter 5F PICC = 5mm vessel diameter Insertion technique Catheter tip position Patient diagnosis Catheter material

9 Can a PICC become a CICC? Yes but technically considered off label use Peripherally inserted central catheter (PICC) versus Centrally inserter central catheter (CICC) Catheter will still terminate in the CAJ / IVC Can be used for most clinical applications Not ideal as a substitute for a CVC in the ICU / ED / OR particularly if on vasopressors / haemodynamic monitoring

10 Why a PICC for a CICC? Use of a micro puncture kit (21G needle versus 18G needle) Large rigid guidewire with CVC kits Can be trimmed to length / tunnelled with ease Reduce vessel trauma when dilating Smaller catheter in bigger vein Ideal for clinicians used to inserting PICCs Safer approach than standard CVC insertion (but be mindful of introducer in a central vein)

11 Best sites for PICC/CICC insertion? Axillary Vein Femoral vein distally placed Low approach IJ Brachiocephalic

12 Liverpool experience with PICC/CICCs Increasing presentation of patients with venous depletion Body habitus or limb contractures precluding PICC placement Patients were being put at greater procedural risk inserting CVCs (thin / emaciated patients) Very familiar with benefits of micro puncture Decision made to use PICCs in lieu of CVCs when appropriate

13 Liverpool experience with PICC/CICCs Patient Characteristics Gender, n % Male Female 41 (48.3) 44 (51.7) Age, mean (SD) Male Female 64 (17.6) 61 (17.3) Clinical Category, n % Aged Care Cardiac Colorectal / Upper GI General Medical General Surgical Haematology / Oncology ICU Neurology Outpatients Orthopaedic / Trauma Renal 8 (9.4) 8 (9.4) 10 (11.8) 8 (9.4) 5 (5.9) 19 (22.4) 9 (10.6) 4 (4.7) 1 (1.2) 3 (3.5) 10 (11.8) Jan 2015 Dec 2016: 85 PICCs inserted outside the arm

14 Liverpool experience with PICC/CICCs Device Characteristics SL PICC DL PICC TL PICC Total Indications, n % Antibiotics 29 (34.1) 13 (15.3) 3 (3.5) 45 (52.9) Chemotherapy 1 (1.2) 13 (15.3) 3 (3.5) 17 (20.0) Poor Vascular Access 9 (10.6) 3 (3.5) 2 (2.4) 14 (16.5) Specific Drug Therapy 1 (1.2) 2 (2.4) 3 (3.5) TPN 5 (5.9) 1 (1.2) 6 (7.1) Anatomical Position, n % Axillary vein Femoral Internal Jugular 18 (21.2) 4 (4.7) 15 (17.7) 16 (75.3) 4 (4.7) 18 (21.2) 4 (4.7) 2 (2.4) 4 (4.7) 38 (44.7) 10 (11.8) 37 (43.5)

15 Liverpool experience with PICC/CICCs Insertion Outcomes Axillary Vein Femoral Vein Internal Jugular Vein Total Complication, n % Arterial puncture 0 1 (1.2) 1 (1.2) 2 (2.4) Failed Access 2 (2.4) (2.4) Malposition 2 (2.4) 0 1 (1.2) 3 (3.5) Nil Complications 34 (89.5) 9 (90.0) 35 (95.0) 78 (91.8) Median Dwell: 16 days (IQR: 8-26) Primary reason for removal: No longer required No CLABSI reported

16 Femoral PICC Placement Femoral lines traditionally used for short term access Up to 3 fold greater risk of CLABSI (compared to SC and IJ) Not usually considered as an option for long term therapy (except paediatrics) Minimal evidence to date on the effectiveness of appropriately placed femoral lines Arvaniti, K., Lathyris, D., Blot, S., Apostolidou-Kiouti, F., Koulenti, D., & Haidich, A. B. (2017). Cumulative Evidence of Randomized Controlled and Observational Studies on Catheter-Related Infection Risk of Central Venous Catheter Insertion Site in ICU Patients: A Pairwise and Network Meta-Analysis. Critical care medicine, 45(4), e437-e448. Zhang, J., Tang, S., Hu, C., Zhang, C., He, L., Li, X., & Xiao, J. (2016). Femorally inserted central venous catheter in patients with superior vena cava obstruction: choice of the optimal exit site. The journal of vascular access, 0. Kanter, R. K., Zimmerman, J. J., Strauss, R. H., & Stoeckel, K. A. (1986). Central venous catheter insertion by femoral vein: safety and effectiveness for the pediatric patient. Pediatrics, 77(6),

17 Femoral PICC Placement Traditional femoral lines: Inserted in emergent situations Puncture site near inguinal groove and placed Difficulty with stabilisation / dressing adherence Most area bad if incontinent Tunnelled femoral PICC/CICC: Inserted under controlled situations Puncture site near inguinal groove Subcutaneous tunnel made 10cm distal to puncture site (catheter exit point) Initial puncture site dressed and heals over by primary wound intention quickly

18 Femoral PICC Placement Traditional femoral line: Tunnelled femoral PICC/CICC:

19 Femoral PICC Placement 3 Year Audit January 2014 Dec femoral PICCs inserted using the distal approach Primary reason for catheter: AB therapy / Poor Access / TPN 13 (60%) were SL 4F PICCs Median Dwell 7 days (IQR: 4.75) Range: 2 days 50 days NO SYMPTOMATIC DVT / NO CLABSI

20 Conclusion: Use of PICCs as CICCs is a viable alternative Safe to insert and manage Can be tunnelled with ease and used as a long term device Tunnelled IJ / Axillary PICCs should be considered for patients having therapy for more than 6 weeks Distally placed femoral PICCs are a good option for patients with poor upper extremity / central access More clinical trials required

21 Questions? Central Venous Access Team Liverpool Hospital: