PICC, port e trombosi cateterecorrelata: la prevenzione è legata alla tecnica di impianto!
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1 PICC, port e trombosi cateterecorrelata: la prevenzione è legata alla tecnica di impianto! Massimo Lamperti MD, MBA! Clinical Professor of Anesthesiology! Cleveland Clinic Lerner College of Medicine! Chief of General Anaesthesiology Department! Cleveland Clinic Abu Dhabi!
2 Disclosures! No conflict of interest to declare related to this topic!
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5 Q/A! Pathophysiology of CR-DVT! Is CR-DVT also catheter-type related?! Can we avoid it?!
6 CR-DVT!
7 CR-DVT! All catheters, when introduced into the body, are progressively covered with plasma proteins and fibrin.! Fibrin formation is a natural process that may occur soon after the insertion of a device or develop at any time during the intra-venous therapy.! This is how the human body attempts to protect itself against a foreign body.!
8 Thrombotic catheter- occlusions types! Fibrin tail or flap: extends from the catheter tip but is drawn inward, blocking the opening of the catheter lumen on aspiration attempts. This results in an ability to infuse fluids but the inability to withdraw blood.!
9 Thrombotic catheter- occlusions types! Mural thrombus: it starts where the catheter touches or "rubs" the vein s wall. Common sites are where this can happen are: the entry site, anywhere along the catheter path, and the catheter tip.!
10 Thrombotic catheter- occlusions types! Fibrin sheat: it starts when fibrin adheres to the external catheter surface, often beginning at the entry site, and may encase all or part of the catheter like a sock. May completely cover the opening of the catheter tip creating difficulty in withdrawing the blood from the catheter.!
11 Thrombotic catheter- occlusions types! Intraluminal thrombus: it occurs when blood refluxes inside the catheter lumen. Common causes of reflux include patient coughing, inadequate flushing after blood draws or after checking for blood return, or improper use of flush syringes.!
12 Thrombotic catheter- occlusions types! Venous thrombosis: this type of thrombosis can be vessel-occlusive. It typically involves the superior vena cava and/or the innominate veins. When it is occlusive, it is associated with a superior cave syndrome.!
13 Risk Factors for Catheter Related Thrombosis!
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16 Can we avoid CR-DVT?!
17 5STEPS! Sonography both 2D and Doppler! Tip central! EKG! Power injectability! Size measurement and choice of the catheter!
18 S- Sonography! Pre-scanning: RACEVA- RAPEVA! Ultrasound-guided cannulation: puncture guidewire- catheter in site! Doppler mode in case of low venous flow in small veins!
19 S- Sonography!
20 T- Tip must be in a central venous location!
21 T- Tip must be in a central venous location!
22 T- Tip must be in a central venous location! 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!
23 T- Tip must be in a central venous location!
24 T- Tip must be in a central venous location! TTE: Apical four chamber view! Easy to perform! 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)!
25 T- Tip must be in a central venous location! TTE: 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)!
26 T- Tip must be in a central Standardization of TTE for tip location! -Tip to be placed in lower 1/3 of SVC! venous location! 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! -Tip to be placed in RA! Apical view: direct tip visualization in RA!
27 T- Tip must be in a central venous location!
28 Ekg- verification! Whenever possible, the correct position of the tip is verified during the procedure via the intracavitary Ekg method!
29 Ekg- verification!
30 Ekg- verification!
31 Ekg- verification!
32 P-ower injectability! Allows rapid infusion of high volumes! Allows high PSI (up to 300)! Allows small calibre! Allows high flexibility!
33 P-ower injectability!
34 P-ower injectability!
35 P-ower injectability! Ultra-resistant polyurethane-made power-injectable catheters seems to reduce the rate of occlusion and thrombosis in ICU patients!
36 P-ower injectability!
37 S-ize! C/V must not exceed 30% of cross-sectional diameter of the vein! Catheter area should not exceed 20% or Vein CSA!
38 S-ize!
39 S-ize! There are several alterations that occur under conditions of low shear rate. Intravascular foreign substances evoke inflammatory reactions and provide surfaces for protein deposition.! The insertion of a catheter may decrease shear stress along the endothelial lining to levels that produce increased viscosity and even further reductions in blood flow.!
40 S-ize! Prospective cohort; n=136, 1 site, Australia! Sharp R, et al. Int J Nursing Studies 2014! Association between catheter#vein#vte! Patients with a C:V ratio > 45%! RR 13.0 ( ) for DVT compared to those <45%! (adjusted for co-morbidities, meds)!
41 S-ize! Catheter to vessel ratio (CVR) may be defined as the indwelling space or area consumed or occupied by an intravascular device inserted and positioned within a venous or arterial blood vessel.! The authors suggest to calculate the real area of the vein occupied by the catheter! They suggest three zones: GREEN 33% or less - safe! YELLOW 34-44% -caution! RED 45% above high risk!
42 Keynotes! CRT is an unseen danger in patients receiving short as long-term central venous access! CRT can be minimize! The introduction of a BUNDLE seems to be more effective than single manoeuvres or preferences! There is still a big debate related to the standardization of outcome!
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Prevention of thrombosis
Prevention of thrombosis Massimo Lamperti MD, MBA Chief of General Anaesthesia Department Anaesthesiology Institute Cleveland Clinic Abu Dhabi Clinical Professor of Anaesthesiology Cleveland Clinic Lerner
Nuovi materiali per la prevenzione di infezione e trombosi: quali evidenze?!
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