Venous Access in Apheresis Daniel Putensen, Apheresis Nurse
Why is Vascular Access so important? Henrikson et al. Adverse events in apheresis: An update of the WAA registry data.transfus Apher Sci. 2016; 54: 2-15
Vascular Access options for Apheresis PERIPHERAL CENTRAL AV Fistula/Graft Peripheral cannulation Non- Tunneled CVC Tunneled CVC Port single/double USG-PIVA Via one arm Via artery
Vascular Access devices 4
Central venous access sites
CVC position
Peripheral venous access sites
Ultrasound visualisation of peripheral cannula
Advantage / disadvantage of VADs ACCESS DEVICE ADVANTAGE DISADVANTAGE Peripheral access Peripheral access using an ultrasound Central venous access Arteriovenous fistula / graft Quick bedside insertion Low complication rates Cheap >90% patients have adequate veins on US Avoids CVC insertions High inlet flow rates Can stay in situ permanently (i.e., Ports) Can provide permanent and effective vascular access Difficult in patients with no veins Needs patient s cooperation Limited inlet flow rates Requires a new skill-set Expensive equipment More severe complications Requires planning - consent, IR slot, CVC team, etc. Requires surgery Requires staff training / input from renal team
Complications Central VAD Pneumothorax Haemothorax Air embolism Venous thrombosis Pinch off syndrome Infection Artery / nerve damage Etc. Peripheral VAD Infection Phlebitis Infiltration Artery / nerve damage Dislocation Stenosis Parienti JJ, Mongardon N, Megarbane B, et. al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015;373:1220 1229 Nuss R, MD, Cole L, Le T, MD, Orsini E, Harned E. Pinch-Off Syndrome in Patients With Sickle Cell Disease Receiving Erythrocytapheresis. Pediatr Blood Cancer 2006. Available from: DOI 10.1002/pbc.21058 McCallum L. Care of peripheral venous cannula sites. Nursing Times 2012; 108:12-15 Padberg FT, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management. J of Vas Sur. 2008;48: 55-80
Factors that determine type of VAD
Vascular Access Experience from 3 different centres
VADs for RBC exchange at Imperial College (Paediatric patients) Ong, M. Using peripheral venous access for automated exchange using Spectra Optia is safe and feasible for sickle cell disease in the paediatric population. Bone Marrow Transplant. 2013; 48:489
USG-PIVA at St. Georges
VADs used at UCLH (2014-2015) 15
USG-PIVA at UCLH Upper arm ACF Lower Arm Basilic Brachial Ceph Ceph Brachial MedCubital Ceph Radial Basilic Cannulation episodes 109x 122x 8x 7x 41x 11x 7x 6x 9x Cannula Size 18g 18g 18g 18g/20g 18g/20g 18g/20g 20g 20g 20g/22g Inlet flow 45ml/min (30-68ml) 45ml/min (42-57ml)=18g 37ml/min (25 42ml)=20g 40ml/min (30-50ml) = 20g 30 ml = 22g Vein depth 5mm (2mm-12mm) 4mm (2mm-7mm) 4mm (2mm-8mm)
USG-PIVA literature overview Author (Year) Study type Apheresis procedure Notes Keyes (1999) Prospective study n/a A&E setting (101 pts; 91% success rate) Hanafusa (2015) Putensen et al. (2015) Salazar et al (2016) Mayhew and Stylianou (2017) Gopalasingam et al (2017) Report GMA 4 pts with poor venous access; total of 33 procedures successfully performed Prospective study RBC exchange 38 pt s; total of 84 procedures of which 85% (71 US cannulations) were successful, 49 CVC avoided Prospective study Retrospective study Prospective, descriptive study TPE, RBC exchange, CC CC TPE, ECP, CC 186 pt s; total of 831 procedures 20% decrease of pt s needing CVC 203 pt s; total of 383 procedures. Decreases CVC insertion from 33% to 7% over the study period Implementation of USG-PIVA in apheresis unit: decrease of CVC insertion from 45.8% (125 CVCs) to 13.2% (30 CVCs)
Access sites
19
Fistula Return line Access line 17 G Fistula needle
How to increase the number of peripherally placed cannulas? Elective Procedure? Make pre-procedure vein assessment mandatory Consider required Inlet Flow rates Cooperation (i.e., patient, parents, play specialist) Consider access sites beyond the ACF area Consider type of peripheral vascular access device Utilise vein-enhancing methods (e.g., warmth, hydration, etc.) Use technology (e.g., near infrared light or ultrasound devices) Etc.
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References for USG-PIVA Keyes et al. Utltrasound-Guided Brachial and Basilic Vein Cannulation in Emergency Department Patients With Difficult Intravenous Access. An Emerg Med. 1999; 34, 711-714 Hanafusa N et al. Deep Vein Puncture Under Ultrasonographic Guidance An Alternative Approach for Vascular Access of Apheresis Theraphies. J Clin Apher [Internet] 2015. Available from: doi: 10.1002/jca.21389 Putensen, D., Pilcher, L., Collier, D., McInerney, K. Ultrasound-guided peripheral deep vein cannulation to perform automated red cell exchange-a pilot study in a single centre. J Clin Apher. 2015;1098 1101. doi:10.1002/jca.21440 Mayhew M, Stylianou J. Ultrasound-guided peripheral vein cannulation reduces the need for central venous catheterization for peripheral blood stem cell harvest procedures. Poster presented at the 43 rd annual meeting of the European Society for Blood and Marrow Transplantation 2017, Marseille, France Salazar et al. Ultrasound-guided peripheral venous access for therapeutic apheresis procedures reduces need for central venous catheters. J Clin Apher [Internet] 2016. Available from: DOI 10.1002/jca.21493 Gopalasingam et al. A successful model to learn and implement ultrasound-guided venous catheterization in apheresis. J Clin Apher [Internet] 2017.Available from: DOI: 10.1002/jca.21533