Tip navigation and tip location for PICCs. Mauro Pittiruti Catholic University, Rome - Italy

Transcription

1 Tip navigation and tip location for PICCs Mauro Pittiruti Catholic University, Rome - Italy

2 What are we talking about? Tip navigation and tip location are two different aspects of central line insertion: Tip navigation = Methods which may be used during the procedure to help the operator in directing the guidewire and/or the catheter in the right direction. Tip location = Methods to verify that the tip of the catheter is in the desired position Tip navigation is useful Tip location is mandatory

3 Part 1: TIP LOCATION OF PICCs

4 Tip location is mandatoryin all PICC insertions Any central venous access device (PICC, CICC, port, PICC-port, dialysis cath., etc.) inserted through of a vein of the upper arm or a vein of the cervicothoracic area should have its tip properly placed in the lower part of the superior vena cava or in the upper part of the right atrium. Correct tip position is of paramount importance to avoid complications such as: venous thrombosis catheter malfunction arrhythmias

5 2009

6 2016

7 tip location methods DURING THE PROCEDURE Intracavitary ECG Fluoroscopy Echocardiography (TTE, TEE) AFTER PROCEDURE Chest x-ray CT, MR, angiography Echocardiography (TTE)

8 Tip location should preferably performed during, rather than after the procedure Post-procedural control of tip location is associated with the possible need for repositioning the tip. Which implies: waste of time waste of resources potential harm to the patient 2016

9 Post-procedural chest x-ray: only in exceptional cases 2016

10 There are three main intra-procedural methods for tip location Intracavitary ECG (IC-ECG) Fluoroscopy Echocardiography

11 Intracavitary ECG (IC-ECG) is the preferred method for intraprocedural tip location Accurate More accurate than radiology Less accurate than trans-esophageal echocardiography (TEE) Inexpensive 100% Safe Easy to perform Easy to learn Applicable to any type of CVAD

12 Tip location should preferably performed by IC-ECG 2016

13 Dedicated ECG monitor or standard ECG monitor? There is little or no evidence that conventional IC-ECG performed by a dedicated ECG device (Delta, Sherlock, Vasonova, Celerity, C3, etc,) is more accurate or more cost-effective if compared to conventional IC-ECG performed by a standard ECG monitor. The only indirect evidence in this regard has been proven for Nautilus vs standard monitor in a multicenter trial on pediatric patients (Rossetti, 2014)

14 Conventional IC-ECG has some limitations of applicability Conventional IC-ECG is based on the interpretation of changes of P-wave Maximal P wave = CAJ In particular: identification of a specific pattern ( increasing P maximal P diphasic P ) Conventional IC-ECG cannot be carried out in conditions in which the P wave is difficult or impossible to identify Atrial fibrillation Pacemaker Other abnormalities of cardiac rhythm with absence or hiding of P wave

15 2016

16 Conventional IC-ECG cannot be used in AF patients (5-7%) P wave is the expression of the synchronized depolarization of the right atrium In AF patients, the depolarization of the right atrium is not synchronized, and the TQ tract do not contain one single P wave but multiple atrial waves

17 Prevalence of AF is higher in older patients (7-10%) JAMA. 2001;285:

18 Prevalence of AF is higher in older patients (7-10%) Clin Geriatr Med. 2012; 28(4):

19 Not only AF Conventional IC-ECG may be difficult also in other conditions (1-2%): - pacemaker (if active at every beat) - some rare cardiac arrhythmias - some cardiovascular abnormalities (persistent left SVC) - when the electric signal is poorly conducted - very small bore catheters (< 3Fr) in neonates -

20 How to perform tip location when conventional IC-ECG is not applicable or not feasible? We have several options: 1) Tip location by alternative methods Fluoroscopy Echocardiography (TEE or TTE or supraclavicular US) Modified IC-ECG ECG interpretation of the TQ tract 2) Tip navigation + post-procedural tip location Doppler navigation Ultrasound navigation IC-ECG for navigation Visual navigation by electromagnetic method (Navigator) 3) Integration of different methods

21 Tip location by fluoroscopy

22 Tip location by fluoroscopy Acceptable as accuracy Though, less accurate than echocardiography or IC-ECG Expensive Unsafe X-ray exposure Logistically difficult Particularly for bedside CVADs (PICC and CICC)

23 Tip location by fluoroscopy: only in exceptional cases 2013

24 Tip location by fluoroscopy: only in exceptional cases 2016

25 Tip location by echocardiography TEE and TTE

26 TEE

27 Tip location by echocardiography (TEE) TEE : Trans-esophageal echocardiography The most accurate method for tip location Invasive Esophageal probe Expensive Logistically impossible in the vast majority of patients Feasible before/during cardiac surgery

28 TEE for tip location: does it work? Anatomical landmark of CAJ = crista terminalis (thickening of the wall located at the cavo-atrial junction)

29 TTE

30 Tip location by echocardiography (TTE) TTE : trans-thoracic echocardiography Accuracy depending on the method used and on the operator Widely used in Europe more than in USA Ideal in neonates and children May be difficult in some adult patients

31 TTE for tip location: does it work? Apical four chamber view Easy to perform Direct visualization of the tip only if it is inside the right atrium Indirect visualization by CEUS (evidence of contrast flow within 1-2 sec after injection = tip is in the lower 1/3 of SVC)

32 TTE for tip location: does it work? Subcostal bi-caval view Requires training Direct visualization of the tip in RA, SVC or IVC May be difficult or impossible in some conditions (obesity, COPD, abdominal surgery)

33 TTE for tip location: does it work?

34 TTE for tip location: does it work?

35 TTE for tip location: does it work?

36 TTE for tip location: does it work? Ideal in neonates and infants Katheria AC(1), Fleming SE, Kim JH. J Perinatol Oct;33(10):791-4 A randomized controlled trial of ultrasound-guided peripherally inserted central catheters compared with standard radiograph in neonates. Division of Neonatology, Department of Pediatrics, University of California, San Diego, CA, USA.

37 2016

38 WoCoVA-GAVeCeLT Consensus, Intensive Care Medicine 2012

39 WoCoVA-GAVeCeLT Consensus, Intensive Care Medicine 2012

40 Detection of the tip during TTE CEUS Contrast infusion (1ml air + 9 ml saline) Color Doppler Saline infusion

41 Sonographic Evaluation of Central Line Placement: SECLiP Study Ultrasound offers immediate assessment of complications, allowing to detect a pneumothorax with up to 95% sensitivity in a supine patient, and it does not expose the patient to radiation With ultrasound, correct tip placement results in immediate visualization of the saline "splash" upon injection. If it takes longer than a second to see, you're probably too proximal. If the tip is inside the atrium you can visualize it directly (Eric Mervis, University of California, 2013)

42 The future of TTE for tip location Standardization of TTE for tip location: 1) Tip to be placed in lower 1/3 of SVC: Subcostal view: direct tip visualization in SVC Apical view: RA visualization + echo-contrast infusion (contrast appearing in RA within 1-2 sec) or saline infusion (color doppler changes in RA within 1-2 sec) Apical view: direct tip visualization in RA + pulling back the catheter until tip disappears 2) Tip to be placed in RA: Apical view: direct tip visualization in RA

43 Tip location by Doppler?

44 Tip location by doppler? (available as Vasonova TLS) Theoretically interesting Expensive methodology Problem: no specific clinical study has ever showed that doppler probe measurement of blood flow is accurate to detect the CAJ (not in normal patients, not in AF patients) Though, one recent study on a non-peer reviewed journal (Girgenti et al., 2014) claimed success in 5 cases of AF Further studies needed

45 Tip location by modified IC-ECG

46 In AF pts, we can adopt a modified IC-ECG for tip location, evaluating the TQ tract and not the P wave Old method - first described in 1989 and studied more recently by our group. - based on the asynchronized depolarization of the atrium, as evident by atrial waves in the TQ tract.

47 Using modified IC-ECG for tip location, evaluating the TQ tract and not the P wave In normal atrium, CAJ = maximal P wave In the fibrillating atrium, CAJ = maximal activity of the atrial waves (in terms of frequency and height)

48 Does it work? Engelhardt 1989 Pittiruti, LaGreca et al Pittiruti, LaGreca et al SVC pattern Right Atrium pattern

49 Engelhardt W, Anaesthesist 38(9):476-9, 1989 Prospective study: ECG location control vs chest X-ray (40 patients with atrial fibrillation.) Main criteria for intracardiac position: Abrupt appearance of high-voltage P-waves when entering the right atrium and their brisk disappearance when pulling the catheter back into the SVC Withdrawal of the catheter until ECG changes show a SVC pattern. Results: correct placement of the catheter tip in the SVC in all patients but one (severe dysrhythmia, intracardiac ECG could not be obtained, despite correct placement on X-ray). Conclusions: 1. Method feasible even in atrial fibrillation 2. False-negatives may occur 3. False-positive are virtually impossible.

50 ECG-controlled placement of central venous catheters in patients with atrial fibrillation (Pittiruti, La Greca, Scoppettuolo et al. - INS 2011) Cavo-atrial junction was detected by two criteria: (a) abrupt appearance of high-voltage waves when entering the right atrium and their brisk disappearance when pulling the catheter back into the SVC; (b) sudden increase (4-fold, 10-fold) of the amount of energy recorded by the intracavitary electrode Post-op. chest x-ray in all patients Cavo-atrial junction correctly identified in 25 pts. out of 27 Conclusion: the modified ECG method for verifying the position of the tip of central venous access devices can be applied in most patients with atrial fibrillation, with high accuracy (no false positives; few false negatives).

51 Intracavitary ECG for tip location in atrial fibrillation patients (Pittiruti, La Greca, Biasucci et al. - AVA 2016) In ten AF patients candidate to cardiac surgery, the tip of the central VAD was placed under TEE control: IC-ECG was recorded in 3 different positions (CAJ; 2cm below CAJ; 2cm above CAJ). An analysis of the IC-ECG showed that the TQ tract was specifically different when the tip was at the CAJ, both qualitatively (multiple high atrial waves) and quantitatively (maximal value of the difference between highest positive peak and lowest negative peak of the atrial waves) Conclusion: in this pilot study, the modified ECG method for verifying the position of the tip of central VADs was 100% accurate in all ten cases (no false positives; no false negative).

52 Tip at the CAJ J tip at the crista terminalis Evident increase in atrial waves

53 Intracavitary ECG for tip location in atrial fibrillation patients (Pittiruti, La Greca, Biasucci et al. - AVA 2016) as the tip is located under TEE control at the crista terminalis ( = CAJ), the height of the atrial waves in the TQ tract is maximal (i.e.: the asynchronous electrical activity of the atrium is maximal); the TQ tract becomes relatively flat in the other two positions (2 cm below the CAJ, in the right atrium; 2 cm above the CAJ, in the SVC).

54 The future (ECG) After this pilot study, our goal is to collect enough data to identify a specific quantitative parameter for the interpretation of the TQ tract at the CAJ: Measurement of the area underlying the positive and negative waves (area = atrial energy), parameter which may be affected by the length of the TQ) Measurement of the widest difference between maximal positive peak and maximal negative peak : probably the most reliable option, since it is independent from the variable length of the TQ

55 The future (ECG) Measurement of the area underlying the positive and negative waves (area = atrial energy), parameter which may be affected by the length of the TQ)

56 The future (ECG) Measurement of the widest difference between maximal positive peak and maximal negative peak : probably the most reliable option, since it is independent from the variable length of the TQ

57 The future (ECG) Other ECG methods?

58 Tip location: conclusions

59 Our current algorithm If a P wave is evident on basal ECG: conventional IC-ECG is enough If a P wave is not evident: In AF patients: Modified IC-ECG + echocardio (TTE) In non-af patients (PM) echocardio (TTE)

60 Our current algorithm Basal ECG P wave is evident P wave is not evident Conventional IC-ECG AF Non-AF No chestx-ray Modified IC-ECG TTE TTE Post-op chest x-ray in only selected cases

61 Part 2: TIP NAVIGATION OF PICCs

62 Tip navigation is useful in all PICC insertions Methods of tip navigation are used during the procedure to help the operator in directing the guide wire and/or the catheter in the right direction. They do not replace tip location methods Still, they are particularly useful to reduce the risk of primary malpositions: - when difficulties of catheter progression are anticipated - when intra-procedural tip location methods are not applicable or not feasible or of difficult interpretation

63 tip navigation methods Visual methods Non-visual methods direct (visualization) ultrasound fluoroscopy Navigator indirect (projection) Sherlock doppler-based VPS pressure-based Catfinder ECG-based Delta

64 tip navigation visual methods

65 tip navigation visual methods They provide information about the position of the catheter tip during its trajectory They help us to identify the wrong direction of the tip - in the ipsilateral internal jugular vein - in the controlateral veins (brachio-cephalic, subclavian, jugular) Some of them can be used to redirect the catheter by proper manipulation. Visual methods: direct (localization) ultrasound fluoroscopy Navigator (Corpak) indirect (projection) Sherlock (Bard)

66 Ultrasound for tip navigation

67 Ultrasound for tip navigation 11

68 Negative Assessment 12

69 69

70 Catheter

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72 Tip navigation by microconvex probe R B CS V C L AB oc AV

73 Supraclavicular US with microconvex : does it work?

74 Supraclavicular US with microconvex: does it work? Theoretically interesting It requires training Probably not applicable to all VADs Useful for tip navigation rather than for tip location Further studies needed

75 Tip navigation by ultrasound with linear probe No additional cost Completely safe The supraclavicular area must be accessible and prepared in advance Very accurate, particularly in pediatric patients Sometime difficult in obese patients It can be used for redirecting the catheter or the guidewire in the right direction, under visual control Easier, safer and more accurate than fluoroscopy

76 ULTRASOUND for tip navigation Many published studies Different US methods have been validated for both tip location and tip navigation The simplest method (supraclavicular scan with linear probe) is easy and highly cost-effective

77 Fluoroscopy for tip navigation

78 Fluoroscopy? You should not use fluoroscopy for tip navigation (or tip location) Is not safe Is not accurate Is not cost-effective Is logistically difficult or impossible for bedside CVADs Seerecommendations of AHRQ 2013, INS 2016, etc.

79 Tip navigation by Navigator

80 Visual, anatomic method of navigation Navigator = old electromagnetic method for tip navigation regarded as a direct visual or anatomic method, since it localize the tip inside the thoracic cage. It may be sometimes used as surrogate tip location

81 The Navigator is wrapped in a sterile cover for US probes

82 The stylet of the PICC is removed and replaced by the stylet of the Navigator

83 Tip in ipsilateral IJV

84 Tip in controlateral BCV

85 Tip at the cavo-atrial junction

86 Tip navigation by using the Navigator: does it work? The Navigator has several advantages if compared to other navigation systems: (a) it can be utilized with any type of central VAD; (b) it tells both the approximated location of the tip below the thoracic cage and its direction; (c) it is highly cost-effective, since it may be used only if required (i.e., when difficulties can be anticipated and/or when they occur during the procedure).

87 Surrogate tip location by using the Navigator Assumption: tip below the 3 rd intercostal space = tip at the CAJ

88 Surrogate tip location by using the Navigator Pittiruti et al.: tip navigation + tip location = an algorithm for maximizing cost effectiveness In 30 PICC insertions, we adopted Navigator for tip navigation and IC-ECG for tip location (performed using Nautilus). The Navigator device consists of a sterile stylet (diameter 1.1 Fr, length 106 cm) placed inside the catheter so that the tip of the stylet is at 1 mm from the tip. During insertion, the tip of the catheter can be followed and detected by an electromagnetic device. Also, the system tells whether the tip is pointing in the right direction or not.

89 Surrogate tip location by using the Navigator In all patients, the tip location verified by IC-ECG corresponded to the electromagnetic detection of the tip below the third intercostal space, with the tip pointing downward. In 3 cases, the Navigator detected that the tip had accidentally entered the ispilateral internal jugular vein and allowed us to correct its direction. In 2 cases, IC-ECG was not confirming the correct tip location, though the PICC had been threaded for the estimated length: the Navigator detected the tip of the catheter in the contralateral brachio-cephalic vein, pointing to the contralateral clavicle: this allowed to correct its direction.

90 Surrogate tip location by using the Navigator An electromagnetic detection of the tip below the third intercostal space, with the tip pointing downward, corresponds to a tip in the proximity of the CAJ. Approximated tip location

91 Tip navigation and tip location by using the Navigator Navigator: - Easy, cost-effective visual method for tip navigation - useful when difficult progression of the catheter is anticipated - Tip location is approximate - May integrate another tip location method

92 NAVIGATOR Abstracts in international conferences No published studies Cost- effective and accurate Currently, limited availability

93 Tip navigation by Sherlock

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98 Sherlock 3CG Many abstracts in international conferences A few published papers on peer-reviewed journals (as from Pub Med)

99 Tip navigation by Sherlock Sherlock is provided as a device integrating tip navigation by electromagnetic method + tip location by IC-ECG Unfortunately: There is no evidence that electromagnetic navigation is actually cost-effective if compared to other navigation methods Also, there is no evidence that coupling electromagnetic navigation with IC-ECG is more effective than IC-ECG alone

100 Anaesthesia Jul 10. doi: /anae [Epub ahead of print] Evaluation of the Sherlock 3CG Tip Confirmation System on peripherally inserted central catheter malposition rates. Johnston AJ, Holder A, Bishop SM, See TC, Streater CT. John Farman Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK. 20.5% malposition (?????) Unacceptable study?

101 2014 NO EVIDENCE THAT IC-ECG BY SHERLOCK 3CG IS ANY BETTER THAN IC-ECG BY ANY OTHER MONITOR!!! NO EVIDENCE THAT ECG-BASED TIP LOCATION + TIP NAVIGATION IS ANY BETTER THAN ECG BASED TIP LOCATION ALONE!!

102 More recently 2015 NO EVIDENCE THAT IC-ECG BY SHERLOCK 3CG IS ANY BETTER THAN IC-ECG BY ANY OTHER MONITOR!!! NO EVIDENCE THAT ECG-BASED TIP LOCATION + TIP NAVIGATION IS ANY BETTER THAN ECG BASED TIP LOCATION ALONE!!

103 2016 NO EVIDENCE THAT IC-ECG BY SHERLOCK 3CG IS ANY BETTER THAN IC-ECG BY ANY OTHER MONITOR!!! NO EVIDENCE THAT ECG-BASED TIP LOCATION + TIP NAVIGATION IS ANY BETTER THAN ECG BASED TIP LOCATION ALONE!!

104 2016 NO EVIDENCE THAT IC-ECG BY SHERLOCK 3CG IS ANY BETTER THAN IC-ECG BY ANY OTHER MONITOR!!! NO EVIDENCE THAT ECG-BASED TIP LOCATION + TIP NAVIGATION IS ANY BETTER THAN ECG BASED TIP LOCATION ALONE!!

105 NO EVIDENCE THAT IC-ECG BY SHERLOCK 3CG IS ANY BETTER THAN IC-ECG BY ANY OTHER MONITOR!!! NO EVIDENCE THAT ECG-BASED TIP LOCATION + TIP NAVIGATION IS ANY BETTER THAN ECG BASED TIP LOCATION ALONE!!

106 Big challenge: Sherlock 3CG To try to prove that IC-ECG + Sherlock navigation has clear advantages over IC-ECG alone in term of cost-effectiveness. (recent study by our group just completed)

107 AVA 2015 Clinical use of Sherlock-3CG for positioning power injectable PICCs Mauro Pittiruti, Giancarlo Scoppettuolo, Laura Dolcetti

108 Goals Tip location with Sherlock-3CG Safety Feasibility Accuracy Tip navigation with Sherlock-3CG Safety Feasibility Accuracy

109 The conclusion of our study The use of SCG was not associated with any complication (100% safety). As regards tip location, SCG showed 94% feasibility and 100% accuracy (though, feasibility might theoretically reach 100% after extended training). As regards tip navigation, SCG showed 81% feasibility and 100% accuracy (feasibility might probably increase, to some extent, after extended training).

110 Problems with Sherlock 3CG Expensive Not cost effective Not easy to use Can be used only with a very specific brand of PICCs Tip location is ok, but tip navigation is not always feasible

111 tip navigation non-visual methods

112 tip navigation non-visual methods They provide generic information about the direction of the catheter. They do not directly identify where the tip is. They are not useful in active redirecting the catheter. They are typically provided in a specific device and coupled with a tip location method Non-visual methods doppler-based VPS pressure-based Catfinder ECG-based Delta

113 Tip location by doppler

114 Vasonova: IC-ECG + Doppler

115 Tip navigation by Vasonova Vasonova is provided as a device integrating tip navigation by doppler method + tip location by IC-ECG Unfortunately: There is no evidence that doppler navigation is actually cost-effective if compared to other navigation methods Also, there is no evidence that coupling doppler navigation with IC-ECG is more effective than IC-ECG alone

116 Vasonova VPS Many abstracts in international conferences No published papers on peer-reviewed journals (as from Pub Med)

117 Girgenti et al Successfully Eliminating Chest Radiography by Replacing It with Dual Vector Technology and an Algorithm for PICC Placement (JAVA, June 2014). 30 patients (5 with AF)

118 Big challenge: Vasonova VPS To try to prove that IC-ECG + Doppler navigation has clear advantages over IC-ECG alone in term of cost-effectiveness. Maybe in AF???

119 Expensive Problems with Vasonova Not cost effective Not easy to use The real role of doppler for tip location is unclear and unproven

120 Tip navigation by pressure measurements

121 Catfinder Elcam

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123 Catfinder (Elcam) A few abstracts available No published paper on peer-reviewed journals (as from Pub Med) A study just completed in our University Hospital

124 The primary endpoint of our study was to evaluate the accuracy of the CatFinder Navigational Device (CFND) as a tip location method for peripherally inserted central venous access devices in adult patients, as compared to the Intracavitary ECG method (IECG). The secondary endpoint was to evaluate CFND as a tip navigation method, able to detect the wrong direction of the catheter during insertion.

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128 Method We studied adult patients candidate to placement of PICCs or PICC-ports. Patients with known ECG abnormalities or cardiac disease of any type were excluded. The target was to place the tip at the cavo-atrial junction. In all cases, tip location was verified by IECG. Any case of suspected wrong direction of the catheter was checked by ultrasound scan.

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130 Conclusions (1) Applicability of CFND was 96% feasibility was 85% safety was 100% (feasibility is expected to improve by solving the technical issues above described)

131 Conclusions (2) - If compared to IECG, accuracy was 84% (considering a range of + 2cm) and 96% (+ 3cm). - Unacceptable tip positions were 3% (in all of these cases, the catheter was too short). - The accuracy in the diagnosis of a malposition in the IJV was 100%.

132 Problems with Catfinder Not cost effective Not easy to use Limited applicability It takes time Accuracy: high for tip navigation, somehow less for tip location

133 Tip navigation by modified IC-ECG

134 Using IC-ECG for tip navigation Available only using a specific dedicated ECG monitor (Delta) Based on the interpretation of the R wave (using a specific reference electrode): it is possible to detect the position of the tip inside the SVC Easy, cost-effective method for tip navigation As for tip location: It cannot differentiate between high and low SVC must be integrated with a landmark measurement method or with some other tip location method - requires a post-procedural verification of the tip unless a reliable tip location method is used during the maneuver

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136 Control electrode

137 Pittiruti et al. : A new technique for catheter tip navigation using intracavitary ECG The new technique was used in 26 PICC placements. In all procedures, IC-ECG-based navigation signal successfully indicated whether the tip was moving towards or away from the CAJ; the catheter tip location at CAJ was confirmed by using the maximum P-wave criterion, as in traditional IC-ECG methods. There were no procedure-related complications

138 Pittiruti et al. : A new technique for catheter tip navigation using intracavitary ECG Reference electrode (upper sternum)

139 Pittiruti et al. : A new technique for catheter tip navigation using intracavitary ECG Negative R (tip hasnotentered the BCV)

140 Pittiruti et al. : A new technique for catheter tip navigation using intracavitary ECG Flat R The tip is below the reference electrode (enteringthe BCV)

141 Pittiruti et al. : A new technique for catheter tip navigation using intracavitary ECG R becomes positive (Tip hasentered the BCV)

142 Pittiruti et al. : A new technique for catheter tip navigation using intracavitary ECG R positive + peak of P (tip at the CAJ)

143 Using IC-ECG for tip navigation The ECG-based navigation method tells whether the tip has entered the BCV and the SVC, but cannot identify the CAJ. Not useful as tip location per se. Though, the same device can be used for IC-ECG tip navigation, conventional IC-ECG tip location and modified IC-ECG tip location

144 Advantages of tip navigation by Delta Easy to use Accurate No additional cost It can be used with any kind of central line It can be done with the same 3 electrodes used for ECG-based tip location Wide applicability (also in cases where ECG based tip location is not applicable)

145 DELTA Abstracts in international conferences No published study yet Very promising: easy, accurate, inexpensive, costeffective

146 Tip navigation: conclusions

147 Tip navigation for PICCs First conclusion There is no hard evidence that tip navigation is necessary during PICC insertion, though it may be useful (or reassuring for the operator). On the contrary, a proper method for tip location is always necessary.

148 Tip navigation for PICCs Second conclusion In most PICC insertions, ultrasound may be the easiest, simplest and most cost-effective method for tip navigation. It accurately detects the wrong direction to the ipsilateral IJV and the right direction into the BCV in adults; it detects the direction inside both BCV and SVC in neonates and infants. Also, it may help the operator to redirect the catheter under visual control.

149 Tip navigation for PICCs Third conclusion There is no evidence to support the use of expensive devices integrating tip location and tip navigation. Thogh, the most promising of such devices is Delta (integration of ECG-based tip location and ECG-based tip navigation). If compared to other similar devices integrating tip location with tip navigation (Sherlock 3CG, Vasonova, etc.), Delta seems to be easier, simpler, less expensive, more accurate and more costeffective.

150 TAKE HOME MESSAGE

151 Tip navigation and tip location for PICCs 1) Avoid fluoroscopy, always 2) For tip location: use conventional IC-ECG whenever possible take intoconsideration TTEand modified IC-ECG in selected cases 3) For tip navigation: use ultrasound scan of the supraclavicular area take intoconsideration ECG-navigation with Delta, if available

152 Thank you for your attention

153 GAVeCeLT th GAVeCeLT Congress - 11th PICC Day December 4th-5th-6th 2017, Florence (Italy)

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