Nuovi materiali per la prevenzione di infezione e trombosi: quali evidenze?!
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1 Nuovi materiali per la prevenzione di infezione e trombosi: quali evidenze?! 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!
3 Risk
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5 PICC complications! Catheter-related bloodstream infections (CRBSI)! -high focus! -never event! Catheter-related thrombosis (CRT)! -hidden problem! -worsen outcomes!
6 PICC-CRBSI! INFECTION! Patients without cancer! Patients with cancer! Incidence! 1.0 to 2.1/1000 catheter days! 1.8 to 7.7 catheter days! Mortality! Estimated 12-25%! Estimated 31-36%!
7 PICC-CRBSI!
8 PICC-CRBSI! THROMBOSIS! Patients without cancer! Patients with cancer! Incidence! 2.0 to 5.5%! (symptomatic thrombosis)! 3.4 to 7.8%! Mortality! 1-2%! 2-4%! (50% higher for cancer patients)!
9 PICC-CRT: risk factors! Endotelial damage! Hypercoagulability! Solutions woth high or low ph or high osmolarity! Traumatic vessel cannulation! Repetitive passes thru subclavian vein! Large catheter size! Previous CVC! Location site! Length of dwell! Abnormalities in clotting factors! Previous DVT! Ethnicity,age! Malignancy! Trauma! Imflammatory process! Pregnancy, hormone replacement! Dehydration, leukocytosis! Multi-lumen catheters! Immobility of blood flow! Vessel compression (tumor)! Small vein size! Venous stasis!
10 Relationship between CRBSI and CRT! Raad 1994! Post mortem exam of 72 cancer patients! Findings:! Fibrin layer on all! Mural thrombus on 38% veins! CR sepsis in 7%! Sepsis only in patients with thrombosis! Timsit 1998! Critical care study! 208 catheters! Findings:! 10 of 139 (7.2%) with CR sepsis without CRT! 13 of 69 (18.8%) with CR sepsis with CRT! When CRT present, risk of CRI increased 2.6 fold!
11 Q/A! Materials?! Tip?! Valved or not valved?! Coating?! What is the final choice?!
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14 Polyurethane PICC lines were found to provide lower rates of infection, dislodgment, thrombus and rupture complications.! Mixed results were found with catheter line occlusions, overall averages showing polyurethane lines slightly higher rates than silicone. Oncology patients however saw opposite results.! Phlebitis rates saw the largest division among the postinsertion complication rates, with 6.7% more phlebitis in the general patient group and 14.5% in the oncology group more for those with polyurethane PICC lines compared with the silicone.!
15 PU catheters are more susceptible to catheterrelated infections and exhibit a higher thrombogenicity, compared to silicone catheters.! Silicone catheters instead exhibit a trend towards decreased mechanical stability.!
16 Retrospective review of 89 Power-PICC lines! No CRBSI! 2 episodes of CRT (in the first 10 days dwell time)!
17 Power-injectable PICC! Up to 300 PSI! Main indication if multiple CT scan are required! Possible infusion up to 300ml/h (with infusion pumps)!
18 Prospectively compared three types of third-generation polyurethane PICCs (power-injectable PICCs with Solo-2 proximal valve (Bard); power-injectable PICCs with PASV (Pressure Activated Safety Valve) proximal valve (Navilyst); and non-valved power-injectable PICCs (Medcomp).! Incidence of occlusion, infection, malfunction and venous thrombosis.! 1 episode of CRT in group B! No CRBSI!
19 Association exists between cutting or trimming peripherally inserted central catheters (PICCs) and the development of deep vein thromboses (DVTs).! Observational, retrospective study was conducted on 634 patients who had a PICC inserted between 2011 and 2012! The first group included patients with a reverse-taper PICC that was cut/trimmed (PC) before insertion (n = 224). The second group was made up of patients whose PICC was not cut/trimmed (PNC) before insertion (n = 410).!
20 A statistically significant difference (P <.001) was found between patients in the PC group who developed a DVT (9.82%) and patients in the PNC group in which PICCs were not trimmed (1.95%).! Further study is required to determine whether PICCs should be reduced in length or whether there is an appropriate method of trimming the catheter to ensure its stability after insertion.!
21 Lifecath PICC Easy!
22 Prospectively compared three types of thirdgeneration polyurethane PICCs (power-injectable PICCs with Solo-2 proximal valve (Bard); powerinjectable PICCs with PASV (Pressure Activated Safety Valve) proximal valve (Navilyst); and nonvalved power-injectable PICCs (Medcomp).! No clinical advantages of valved vs. non-valved PICCs!
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28 Protected PICC technology! Antibiotic impregnated PICC (Cook Spectrum Turbo-Ject PICC)! Antimicrobial impregnated PICC (Arrow PICC with Chloragard Technology)! These technologies damage the cell wall and inhibits bacterial growth of bacterial and/or fungal pathogens!
29 Protected PICC technology! Antibiotic technology! Antimicrobial technology! Bacteriostatic or bactericidal! -against Gram pos! -very weak against Gram neg! -ineffective against fungal pathogens! Bactericidal! -effective against Gram pos and neg! Disinfectant! Used on solid surfaces! Stop bacterial from multiplying! Fungicidal! -effective against fungal pathogens! Antiseptic! Used on human skin! surfaces! Damages cell wall inhibiting cell function!
30 Cook Spectrum Turbo-Ject PICC! Polyurethane, 60 cm, trimable! Minocycline and Rifampin (synergistic action)! Action on Gram pos and neg!
31 Cook Spectrum Turbo-Ject PICC! Impregnation on internal and external surface! Combination of Minocycline and Rifampin makes the color orange!
32 Cook Spectrum Turbo-Ject PICC! Contraindications! Allergy to minocycline and rifampin! Pregnancy! Resistance! Questions raised about the development of resistance! Literature support this! Evidence! In vitro study showing 15mm zone of inhibition >30days (Sheretz 1993)!
33 Arrow PICC with Chloragard Technology! Chlorexidine (CH) is very effective bactericidal! CH fast acting, damaging cell wall! CH very effective when combined with alcohol (Adams 2005)! CH strongly binds to proteins in skin and mucosa! Antimicrobial activity of CH is not affected by presence of blood!
34 Arrow PICC with Chloragard Technology! Chlorexidine (CH) is bonded to catheter! After 24hrs, CH is relased out of catheter surface into surroundung tissue, thus limiting infection at entry site! Slow release!
35 Arrow PICC with Chloragard Technology!
36 Arrow PICC with Chloragard Technology! Contraindications! Allergy to CH! Resistance! Unlikely! Evidence! Only animal studies! Log reduction claim supported by FDA clearance!
37 Patients in 3 high-risk units were randomly assigned to receive either a CHG-impregnated or non-chg PICC line! 167 patients! No differences were noted in the development of CLABSI and VTE between the CHG and non-chg groups.!
38 19 consecutive patients, observational data! Antibiotic impregnated PICC lines decrease the bacteremia rate in our burn population.! This has potential benefits for both patient morbidity and mortality as well as potential cost savings for the healthcare system.!
39 Antithrombogenic PICC technology! Angiodynamics Bioflo with Endexo Technology! Arrow PICC with Chloragard Technology!
40 ! Angiodynamics Bioflo with Endexo Technology! G o a l s f o r n o n - e l u t i n g technology! -resists accumulation of platelets and thrombus! -added into polyurethane during catheter manufacturing! -designed to passivate the catheter surface! -permanent surface modification!!
41 ! Angiodynamics Bioflo with Endexo Technology! 87% reduction of thrombus accumulation on catheter surface over 2 hours (Larue 2012)! Not clear benefit on catheter occlusion!
42 Angiodynamics Bioflo with Endexo Technology! Contraindications! Hypercoagulopathy unless patient is on anticoagulation therapy! Patient with known tape or adhesive allergies! Flushing/pressure injection! Requires heparinized saline! Single lumen: 3.5cc/sec! Double lumen: 4cc/sec! Length of antithrombogenic activity! Not specified!
43 !! Arrow PICC with Chloragard Technology! CH reduces thrombus accumulation on catheter surface by inhibiting thrombin formation! 62% reduction in thrombus formation after 30 days! 51% reduction in flush pressure!
44 ! Arrow PICC with Chloragard Technology!!
45 Arrow PICC with Chloragard Technology! Contraindications! Hypercoagulopathy unless patient is on anticoagulation therapy! ALLERGY TO CH! Flushing/pressure injection! Saline or heparinized saline! Single o double lumen: 5cc/sec! Length of antithrombogenic activity! 30 days!
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48 Right choice! 1. Patient first! 2. Length of therapy! 3. Technique! 4. Management! 5. Technology!
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50 CCAD data Q ! PICC CLABSI: 0.3/1000 indwelling days! CICC 1.1/1000 indwelling days! FICC 3.2/1000 indwelling days! No more FICC- now in training process for tunnelling! CR-DVT: as now 12% asymptomatic DVT treated, no symptomatic DVT!
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