Vascular Access Service Dott.ssa Alessandra Palo Direttore AAT Pavia - SAV Dipartimento Medicina Intensiva Fondazione IRCCS San Matteo Pavia

Transcription

1 Vascular Access Service Dott.ssa Alessandra Palo Direttore AAT Pavia - SAV Dipartimento Medicina Intensiva Fondazione IRCCS San Matteo Pavia Our story so far

2 More and more patients with chronic illness

3 Vascular access everywhere Vascular access devices More than 5 millions of CVCs inserted every year

4 Our origins Our hospital specialized in OncoEmatology and organ transplantation This led to a strong demand of advanced vascular access devices

5 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

6 Procedures 900 Procedures

7 Our areas of expertise 360 vascular access Outpatient-centered Totally US-guided X-ray free H24 mobile phone (calls, SMSs and WhatsApp)

8 Selection Training Counselling 360 vascular access = SAV Insertion Management Complications

9 CICC Totally Implantable Vascular Access Devices Tunnelled and dialysistunnelled devices 360 vascular access = SAV Adult and pediatric PICC MIDLINE PORT

10 Experts Nurses Visiting physician 360 vascular access = SAV Adult and pediatric Residents Trainees Consultants

11 DEVICE CHOISE CVC short term (CICC) CVC long term (> 30 days) INFORMED CONSENT

12 Dialysis and apheresis High-flow catheters Tunneled short & long-term Drug-linked patency Jugular or femoral access LONG TERM CVC

13 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

14 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

15 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

16 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

17 CICC Centrally Inserted Central Catheter CVC PICC Peripherally Inserted Central Catheter

18 Midline vs. PICC Same insertion CVC NOT a CVC

19 CVC Not CVC PVC MiniMidline Midline PICC

20 PICC Central Catheter Peripherally Inserted

21 PICC 600 PICC

22 PICC-Related Thrombosis Big catheters in small veins It is considered the most important issue related to PICCs Not well known

23 PICC-RT The first real-world study to describe early onset PICC-RT Weekly US screening Recruiting, stop 31 st Dec 2017, n=300

24 Insertion Effectiveness Safety

25 Total US-guide Always RACEVA/RAPEVA Choose the right vein/the right side) SAV insertion bundle Simulate during LA Always check the guidewire before dilation Tip-navigation and - confirmation: best performance/complications Bubble-test: check iv position

26 From blindess to ultrasounds Always use US

27 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)

28 Neck-High Neck-Low Neck-Lateral Ax SX Ax LX

29 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)

30 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.

31 Is there the vein? What to look at during RACEVA/RAPEVA Anatomical relations? Thrombosis? Diameter!!! Depth

32 Vein: CVC ratio 2:1 minimum 3:1 best

33 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

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35 SAV Pavia 2016 (N~1000) 0.0% failure 0.0% complications RIJV Others

36 TIP POSITION

37 WHY IS TIP POSITION SIGNIFICANT? CLOSE TO THE HEART High flow No trauma FAR FROM THE HEART Low flow Stenosis Perforation IN THE HEART Malfunction Perforation Arrhythmias

38 Confirm the final position of the catheter tip as soon as clinically ECG CEUS Fluoroscopy RX appropriate.

39 TIME Wikidoc.org

40 LCT has disappeared from Literature No cases from 2000 Place the tip of CVC outside of the atrium

41 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

42 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???

43 High SVC: not for a long time Low SVC-High RA Low RA-RV: pull back

44 Far from SVC/RA junction = More thrombosis and malfunction Distal RA = Arrhythmias

45 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

46 Chest-RX interpretation is inconstant

47 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 ULTRASOUND Flush test!

48 The flush test It s a very useful test to confirm intravenous position of the tip

49 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

50 CEUS limitations 2 skilled operators needed Cardiologic probe Subjective (learning curve) Tricky to document

51 RX free Written protocol

52 Tip navigation

53 Significant primary malposition rate of PICC and CICCs (not from RJV) is 10-30%

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55 Tracking Real time tracking of device direction in comparison to the heart To avoid primary malposition Less complications and optimal function Actual and precise tip position in comparison to the heart Location

56 NAVIGATION: intraprocedural method by definition Fluoroscopy Ecography Electromagnetic tracking

57 US are extremely useful but their role in tip location is still controversial

58 Tracking systems Cathfinder Navigator Vasonova (Arrow VPS G4) Sherlock

59 Electromagnetic tracking + iecg confirmation

60 Is the post-procedural chest X- ray sufficient? No Precise or not it s not intra-procedural

61 Immediate use Intravenous position Bubble tests Long-term use Precise tip position iekg

62 US are extremely useful but can t be used to exactly locate the tip of our devices

63 BBraun iekg

64 S-A node The tip of the device is used as an intracavitary moving lead electrode Anatomical basic: SAN is the most accurate marker of CAJ A-V node

65 The CVC tip becomes the negative terminal of lead II

66 iekg techniques Metallic guidewire vs. fluid column Home-made vs. ad-hoc Adaptors vs. iekg dedicated equipments

67 Cavo rosso (o verde) Derivazione D2

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69 Applicability 90-95% 99.3% Patients with no visible P wave at the standard baseline ECG were exclude Requisiti onda P

70 Still in use today!

71 Pediatric access

72 A real problem Children s veins are smaller Often no suitable kit is available

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74 The best sets are the ones in PICCs trays

75 Real-time ultrasound techniques (anatomy, puncture, navigation, localization.) have their greatest usefulness in pediatrics and are also easier

76 Smaller probes

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78 Sovraclavear approach to the innominate vein in the newborn

79 Tunneling in pediatrics

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81 Tunneling can address the lack of dedicated catheters

82 Correct tip location is vital in children

83 Management

84 Insertion Bundle CDC Management

85 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

86 Ethanol lock

87 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.

88 Antibiotics and biofilm Organism Antibiotic MIC or MBC (mcg/ml) MIC in biofilm (mcg/ml) S. aureus (NCTC ) P. aeruginosa (ATCC 27853) E. coli (ATCC 25922) Vancomycin 2 (MBC) 20 Imipenem 1 (MIC) >1,024 Ampicillin 2 (MIC) 512 P. pseudomallei Ceftazidime 8 (MBC) 800 S. sanguis Doxycycline (MIC) 3.15 Donlan RM, Clin Microbiol Rev. 2002

89 Antimicrobial lock Antibiotics Non antibiotics Vancomycin Gentamycin Cefazoline Cefotaxime Ciprofloxacin Citrate Taurolidine Urokinase (B-I) Ethanol

90 Ethanol lock High efficacy Extremely high concentration Extremely low dose No side effects

91 NCT 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!)

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