Reducing catheter-related thrombosis using a risk reduction tool centered on catheter to vessel ratio

Risk Factors of Catheter-Related Thrombosis in Elderly Patients with Lung Cancer Based on Thromboelastography: A Retrospective, Case-Control Study

Catheter-related thrombosis (CRT) poses serious risks for cancer patients. Identifying risk factors and implementing targeted interventions can prevent CRT. To explore thromboelastogram parameters and clinical risk factors for CRT in elderly lung cancer patients. A total of 663 elderly lung cancer patients were selected from three hospitals in Hunan, Hainan, and Qinghai provinces in China from January 1, 2022, to June 30, 2024. The patients were divided into two groups: a CRT group (221 patients) and a non-CRT group (442 patients), with a ratio of 1:2. A between-group comparison and binary logistic regression were used to analyze risk factors for CRT in elderly lung cancer patients. Binary logistic regression analysis showed that decreased R (odds ratio [OR]: 0.849, 95% confidence interval [CI]: 0.763-0.945, p = 0.003), decreased K (0.571, 95% CI: 0.404-0.807, p = 0.001), advanced age (OR: 1.073, 95% CI: 1.033-1.113, p < 0.001), elevated platelet count (OR: 1.006, 95% CI: 1.004-1.009, p < 0.001), increased hemoglobin level (OR: 1.020, 95% CI: 1.009-1.031, p < 0.001), shortened PT (OR: 0.904, 95% CI: 0.830-0.985, p = 0.022), surgery ≤ 1 month (OR: 2.258, 95% CI: 1.420-3.590, p = 0.001), male sex (OR: 4.534, 95% CI: 2.815-7.304, p < 0.001), diabetes (OR: 2.478, 95% CI: 1.373-4.472, p = 0.003), hypertension (OR: 2.386, 95% CI: 1.505-3.784, p < 0.001), physical activity disorders (OR: 9.038, 95% CI: 4.462-18.309, p < 0.001) were independent risk factors for CRT in elderly lung cancer patients. Independent risk factors for CRT in elderly lung cancer patients include decreased K-values and decreased R-values, shortened PT, advanced age, elevated platelet count, increased hemoglobin level, surgery ≤ 1 month, male sex, diabetes, hypertension, and physical activity disorders.

Ultrasound-guided axillary artery cannulation in the infraclavicular area: A step-by-step approach

Percutaneous arterial cannulation for arterial catheter placement is a commonly performed procedure in intensive care. In many cases routinely cannulated radial arteries may be inaccessible because of shock, arteriosclerosis, or vasoconstriction. In this scenario, femoral or axillary artery may be chosen for arterial catheter placement. Percutaneous cannulation of the axillary artery via the infraclavicular route has two main advantages over cannulation of the femoral artery: avoidance of cannulation of the artery affected by arteriosclerosis and microbiological safety by avoiding cannulation in the inguinal area. This paper describes ultrasound-guided, real-time infraclavicular cannulation of the axillary artery for arterial catheter placement in critically ill patients. The cannulation technique is described in a step-by-step manner. In addition, the limitations of this arterial approach are presented together with the indications and contraindications. The pitfalls that are likely to occur during cannulation via the infraclavicular route are also reviewed.

Femoral to abdomen tunneling at the bedside for medium/long term venous access

BACKGROUND

Femoral to abdomen tunneling of small-bore central venous catheters is a bedside technique for patients with contraindications to a thoracic approach, or as an alternative to a lower extremity catheter exit site.

METHOD

A femoral to abdomen tunneling technique was implemented for patients receiving medium and long-term intravenous treatments with contraindications to the thoracic venous approach or as an alternative to a lower extremity catheter exit site. All venous access devices were inserted with ultrasound guidance under local anesthesia, and catheter tip placement assessed by post procedural radiography.

RESULTS

In this case series, from January 2020 to January 2023, a total of eight FTA-tunneled venous access devices were inserted. There were seven ambulatory patients and one bedbound patient. The median length of the subcutaneous tunnel was 20 cm, ranging from 15 to 27 cm. The median length of the intravenous catheter to the terminal tip was 31 cm, ranging from 23 to 40 cm. Tip location was confirmed by post-procedural abdominal radiograph. The catheter tip locations were interpreted to be at the level of T8-T9 (2), T12 (1), L4 (2), L2 (2), L1(1).No insertion or post insertion related complication was reported. Six patients completed the scheduled intravenous treatment. One patient was unable to be tracked due to transfer to an outside facility. One catheter initially demonstrated to be coiled over the left common iliac vessel was repositioned using a high flow flush technique. There was one reported catheter dislodgment by the nurse providing care and maintenance. The overall implant days were 961, with a median dwell time of 125 days ranging from 20 to 399 days.

CONCLUSION

Femoral to abdomen tunneling provides an alternative exit site useful in select patients with complex intravenous access. The data of this small retrospective review suggests this a safe and minimally invasive bedside procedure.

Comparing arterial catheterisation by palpation or ultrasound guidance by novice nurses in an adult intensive care unit: A prospective cohort study

BACKGROUND

Arterial catheterisation is a common procedure in intensive care units (ICUs), typically performed using the palpation technique. Ultrasound (US)-guided catheterisation remains underutilised, particularly when performed by nonphysician operators.

OBJECTIVE

The objective of this study was to assess the effectiveness of US-guided arterial catheterisation performed by nurses in critically ill patients.

METHODS

This prospective cohort study took place in a medical ICU at a tertiary university hospital, comparing outcomes before and after a training program. Critically ill patients requiring arterial catheterisation were included. The study examined the performance and complications associated with two catheterisation techniques used by critical care nurses: palpation (PP) and US-guided. Nurses inexperienced with the US technique completed a brief training program consisting of two 3-h workshops followed by supervised clinical practice before performing the procedure. Collected data included the first-attempt success rate (primary endpoint), overall success rate, procedure time, the number of attempts, the number of cannulas used, complication rate, and catheter durability.

RESULTS

The study included 175 patients, with 89 in the PP group and 86 in the US group. Baseline characteristics were similar between groups. The first-attempt success rate was 50% in the PP group and 58% in the US group (p = 0.39, 95% confidence interval -23.4% to +8.3%). No significant differences were observed between groups in terms of failed attempts (21.3% vs. 14%, p = 0.28), procedure time (284 s vs 350 s, p = 0.44), or rates of immediate (haematoma) and late (catheter infection or dysfunction) complications. Catheter durability was also comparable. Although radial artery cannulation was preferred in both groups, femoral and brachial access were more frequently used in the US group (12.9% and 2.9% vs. 17.6% and 14.9%, respectively, p = 0.02).

CONCLUSIONS

Arterial catheterisation using US guidance, performed by nurses with limited prior experience after a brief training course, demonstrated similar performance and complications rates compared to the traditional PP technique in a medical ICU setting.

Fluid Dynamic and in Vitro Blood Study to Understand Catheter-Related Thrombosis

PURPOSE

Central venous catheters (CVCs) provide a direct route to the venous circulation but are prone to catheter-related thrombosis (CRT). A known CRT risk factor is a high catheter-to-vein ratio (CVR), or a large catheter diameter with respect to the indwelling vein size. In this study, the CVR's effect on CVC hemodynamics and its impact on CRT is investigated with in vitro and in silico experiments.

METHODS

An in vitro flow loop is used to characterize the hemodynamics around CVCs using particle image velocimetry. In addition, CRT is investigated using an in vitro flow loop with human blood and clinical catheters. The wall shear rate of flow around the CVC is computed numerically. CVRs of 0.20, 0.33, and 0.49 and Reynolds numbers of 200, 800, and 1300 are evaluated. No flow is used through CVC lumens to model chronic indwelling catheters.

RESULTS

Results show CVR ≥ 0.33 promotes platelet-rich clot growth at the device tip and at an increased rate compared to lower CVR cases. A high wall shear rate gradient on the CVC tip and an extended wake distal to the tip exists for higher CVR cases, promoting the aggregation of platelets and subsequent stagnation for clot formation. Further, the combination of the CVR and Reynolds number are crucial to CRT potential, not the CVR alone. Specifically, thrombosis risk is increased with low (stasis driven) and/or high (platelet activation driven) flow conditions, with the CVR and CVC's geometry playing an additional role in promoting fluid mechanic driven thrombus development. A high CVR (≥ 0.33) and high flow condition (≥ 1300) results in the highest risk for clot growth at the tip of the device; other locations of the device are at risk for thrombus development in lower flow conditions, regardless of the CVR. The importance of the device geometry and flow in promoting thrombus and fibrin sheath formation is also shown for the device investigated.

CONCLUSIONS

This work demonstrates that the CVR, flow, and device geometry affect CRT. For clinical cases with CVR ≥ 0.33 and/or Re ≥ 1300, the device tip may be monitored more consistently for clot formation. Thrombosis risks remain on the entire catheter, regardless of the flow condition, for a CVR = 0.49. Device placement should be chosen carefully with respect to the combination of the Reynolds number and CVR. Further study is needed on the effect of catheterization to confirm these findings.

Development of a large diameter in vitro flow loop thrombogenicity test system

BACKGROUND

To accommodate a wider range of medical device sizes, a larger in vitro flow loop thrombogenicity test system using 9.5 -mm inner diameter (ID) tubing was developed and evaluated based on our previously established 6.4 -mm ID tubing system.

METHODS

Four cardiopulmonary bypass roller pumps were used concurrently to drive four flow loops during testing. To ensure that each pump produced a consistent thrombogenic response for the same material under the same test conditions, a novel dynamic roller occlusion setting method was applied. Five materials with varying thrombogenic potentials were tested: polytetrafluoroethylene (PTFE), silicone, 3D-printed nylon, latex, and nitrile rubber (BUNA). Day-old bovine blood was heparinized to a donor-specific concentration and recirculated through the flow loops containing test materials at 20 rpm for 1 h at room temperature. Material thrombogenicity was characterized by measuring the thrombus surface coverage, thrombus weight, and platelet (PLT) count reduction.

RESULTS

The larger tubing system can differentiate thrombogenic materials (latex, BUNA) from the thromboresistant PTFE material. Additionally, silicone and the 3D-printed nylon exhibited an intermediate thrombogenic response with significantly less thrombus surface coverage and PLT count reduction than latex and BUNA but more thrombus surface coverage than PTFE (p < 0.05).

CONCLUSION

The 9.5 -mm ID test system can effectively differentiate materials of varying thrombogenic potentials when appropriate pump occlusion settings and donor-specific anticoagulation are used. This system is being assessed in an interlaboratory study to develop standardized best practices for performing in vitro dynamic thrombogenicity testing of medical devices and materials.

Ultrasound-Guided Venous Catheter Placement in Prone Position

The prone position is often used for patients with adult respiratory distress syndrome and specific surgical postures. When performing venous cannulation in this position, it is important to have a structured review to introduce the available major veins and ultrasound-guided procedure. In this review, we discuss the techniques of ultrasound-guided cannulation and provide insights into various aspects, including the anatomical locations of veins, vein sizes, placement techniques, surrounding structures at risk, and reported experiences with catheter placements. Eight major veins can be accessed in the prone position: the internal jugular vein, external jugular vein, brachiocephalic vein, basilic vein, mid-thigh femoral vein, popliteal vein, posterior tibial vein, and small saphenous vein. To minimize the risk of venous thromboembolism, the ratio of catheter diameter to vessel diameter should be less than 0.67. The review also presents the minimal requirement of venous diameter for different catheters in a tabulated form. For larger veins, real-time ultrasound guidance with the long-axis view/in-plane technique is suggested, while for smaller vessels, the short-axis view/out-of-plane technique is recommended. The review includes sonographic illustrations of the two techniques and surrounding arteries and nerves for the eight major veins. The aim of this review is to help clinicians assess the eight major veins and safely insert various types of catheters for patients in the prone position.

Upper Limb Deep Venous Thrombosis Associated With Peripherally Inserted Central Catheters in Hospitalised Surgical Patients

Introduction Surgical inpatients frequently require peripherally inserted central catheters (PICCs) for parenteral feeding and administration of medication. PICCs may cause upper limb deep venous thrombosis (ULDVT), which impacts patient morbidity. We investigated the risk and prevention of PICC-ULDVT in hospitalised surgical inpatients. Methods We conducted a retrospective analysis of 168 consecutive surgical inpatients who received a PICC over the same four-year period. Data from 136 additional consecutive general medical inpatients with PICCs over the same period were included for comparison. We observed and compared the incidence of ULDVT confirmed on dedicated upper limb venous imaging in the cohort of surgical patients compared to a time matched cohort of medical patients. We extracted data including patient demographics, details of admission, and insertion site of the PICC from the hospital electronic notes. Results The incidence of ULDVT in surgical patients was 4.7% compared to 1.5% in medical patients despite increased age (p=0.001) and comorbidity burden (p=0.001) in the latter group. Ninety percent of surgical patients had abdominal surgery within 30 days of PICC placement. Regression multivariate analysis identified concurrent cancer (p=0.048), median Charlson Comorbidity Index (CCI) (p=0.034), admission with malignant bowel obstruction (p=0.002), and catheter insertion into the brachial vein (p=0.033) as significant risk factors for PICC-ULDVT in hospitalised surgical patients. Standard pharmacological venous thromboembolic events (VTE) prophylaxis, as per national guidelines, did not reduce the risk of PICC-ULDVT. Conclusion Our study indicates that surgical inpatients are at greater risk of developing PICC-associated upper limb deep vein thrombosis (ULDVT) compared to medical inpatients, with limited evidence supporting the effectiveness of pharmacological thromboprophylaxis in reducing this risk. PICCs should be used with caution in patients with cancer, cancer-related bowel obstruction, and surgical patients with a higher comorbidity index. PICCs inserted via the basilic vein may reduce ULDVT risk, but further studies are needed on the preferential site of insertion in surgical patients.

A GAVeCeLT bundle for PICC-port insertion: The SIP-Port protocol

In the last decade, a new type of brachial port has been introduced in clinical practice, the so-called "PICC-port." This is a brachial port, but inserted according to the methodologies and technologies currently adopted for the insertion of peripherally inserted central catheters (PICCs). Several studies have shown that PICC-port insertion is safe, not associated with any relevant immediate or early complication, and that the expected incidence of late complications is significantly lower if compared to "traditional" brachial ports (i.e. inserted without ultrasound guidance). Furthermore, PICC-ports yield excellent esthetic results and are associated with optimal patient compliance. This paper describes an insertion bundle-developed by GAVeCeLT, the Italian Group of Long Term Venous Access Devices, and nicknamed "SIP-Port" (Safe Insertion of PICC-Ports)-which consists of few evidence-based strategies aiming to further minimize all immediate, early, or late complications potentially associated with PICC-port insertion. Also, this insertion bundle has been developed for the purpose of defining more closely the differences between a traditional brachial port and a PICC-port. The SIP-Port bundle is currently adopted by all training courses on PICC-port insertion held by GAVeCeLT. It includes eight steps: (1) preprocedural ultrasound assessment utilizing the RaPeVA (Rapid Peripheral Venous Assessment) protocol; (2) appropriate skin antiseptic technique and maximal barrier precautions; (3) choice of appropriate vein, in terms of caliber and site; (4) clear identification of the median nerve and of the brachial artery during the venipuncture; (5) ultrasound-guided puncture and cannulation of the vein; (6) ultrasound-guided tip navigation; (7) intra-procedural assessment of tip location by intracavitary ECG or by trans-thoracic echocardiography; (8) appropriate creation and closure of the subcutaneous pocket.

End-stage renal disease in a critical patient with superior vena cava syndrome with central vein catheters inserted via the superficial femoral vein: A case study

Superior vena cava syndrome (SVCS) is caused by obstruction to the blood flow through this vein. Indwelling central venous devices, such as cardiac pacemakers and haemodialysis catheters have emerged as the most common benign aetiology of SVCS. SVCS is particularly severe in patients with end-stage renal disease who require continuous renal replacement therapy plus infusion therapy. The presence of SVCS results in a reduction of available venous access for affected patients. Therefore, venous access plays a crucial role in the management of these patients. The importance of dealing with vascular access (VA) in critical patients with these conditions cannot be overstated. This case describes an 81-year-old man with respiratory failure who had end-stage renal disease complicated with SVCS. Using ultrasound-guided puncture, we inserted a peripherally inserted central catheter (PICC) into the superficial femoral vein to meet his infusion requirements in intensive care. After successful placement, the catheter tip position was adjusted using imaging to position the tip relative to the haemodialysis catheter. Whenever patients with severe renal dysfunction are treated, central veins should be preserved. Safe PICC access is possible via the superficial femoral vein to protect the last central VA for rational use. This meets urgent needs for infusion and deserves promotion.

Safe Insertion of Arterial Catheters (SIA): An ultrasound-guided protocol to minimize complications for arterial cannulation

Direct puncture and cannulation of peripheral arteries is frequently performed in critical care and in emergency settings, mainly for hemodynamic monitoring and blood sampling. While there is abundant literature on peripheral arterial cannulation in children and adults, there is still scope for clinical improvements which may impact on patient safety. Although the radial artery is the most frequently utilized access site today, due to its superficial proximity, ease of access, and low risk of adverse events, other sites are sometimes chosen. The authors propose the Safe Insertion of Arterial Catheters (SIA) protocol, an ultrasound-guided insertion bundle applying a systematic approach to arterial cannulation, with a focus on improving insertion practices, reducing procedural complications, increasing the patient safety profile, and improving device performance.

Incidence and risk factors of complications during central venous access devices removal in children

PURPOSE

To quantify the rates and identify risk factors for the complications of central venous access devices (CVADs) removal in children.

METHOD

Retrospective (2018-2023) review of children undergoing CVADs removal at a single institution. Data are reported as frequency, percentages and median. Logistic regression analysis was used to identify risk factors associated with difficult removal. Receiver Operating Characteristic Curve (ROC) analysis was conducted to identify the age cut-off and positive likelihood ratio (+LH) for the indwelling time associated with complicated removal. p-Value <0.05 were considered statistically significant.

RESULTS

We identified 208 CVAD removals with a median age of 7.2 (0.2-18.4) years including 116 (55.8%) males. The median CVAD placement duration was 1.26 years (0.4-5.7) years. Indications for insertion included acute lymphoblastic leukaemia (ALL; 78/208, 37.5%), lymphomas (31/208, 14.9%), other malignancies (58/208, 27.9%). Removal indications included completion of treatment (144/208, 69.2%), infection (22/208, 10.6%), malfunction (7/208, 3.4%) and other reasons (35/208, 16.8%). There were 20 (9.6%) complications characterised by difficulty removing the CVAD. Complicated removals were more likely to occur in children with ALL as the primary diagnosis (p = 0.001); independently of the indication for insertion, longer indwelling time was associated with higher risk of complicated removal (p < 0.001). Indwelling time >2.09 years was associated with a 2.87 increased risk of difficult removal.

CONCLUSION

In our experience, almost 10% of CVAD removals in children result in complications. These findings are associated with an indwelling time >2 years; strategies to prevent complicated removals should be considered in children requiring long-term central venous access.

The Use of a High Flow PICC Catheter for Stem Cell and Lymphocyte Apheresis: The Initial Experience of a Pediatric Oncology Center in Brazil

BACKGROUND

Autologous hematopoietic stem cell transplant (HSCT), characterized by high intensity chemotherapy followed by the infusion of HSC previously collected from the peripheral blood, is a procedure used in the treatment of several malignancies. In pediatrics, the apheresis procedure represents a challenge, due to the need for insertion of a rigid central venous catheter (CVC) in small children. The CVC is usually used for stem cell collection and then removed. Later, the patient will need a new device for cell infusion.

AIM

We propose the use of one single catheter for both apheresis and infusion.

METHODS

We present five children between 1 and 13 years of age who underwent apheresis using a high flow PICC catheter surgically inserted.

RESULTS

All patients utilized a PICC line double lumen 5Fr (PowerPICC™ 5Fr DL BARD/USA) placed in the brachiocephalic vein tunneled on the chest, inserted under 24 h prior to apheresis to assure the devices were pervious. Three of the patients were diagnosed with solid tumor and one with acute lymphoblastic leukemia (ALL) awaiting Car-T Cell therapy. The four children who underwent autologous HSCT used the same catheter for cell infusion and remained with the catheter following discharge. The child who was submitted for Car-T Cell still awaits infusion and the catheter was removed.

CONCLUSIONS

High flow PICC is a viable alternative for apheresis to maintain an adequate flow of 5 ml/s and can be used as a single catheter throughout the HSCT process, reducing the risks from anesthesia and the catheter insertion procedure.

TYPE OF STUDY

Clinical Research.

Risk of deep venous thrombosis associated with peripherally inserted central catheter: A retrospective cohort study of 11.588 catheters in Brazil

INTRODUCTION

Deep Venous Thrombosis (DVT) due to Peripherally Inserted Central Catheter (PICC) is one of the most threatening complications after device insertion.

OBJECTIVE

To assess the rate of PICC-associated DVT and analyze the risk factors associated with this event in cancer and critically ill patients.

METHODS

We conducted a descriptive, retrospective cohort study with 11,588 PICCs from December 2014 to December 2019. Patients ≥ 18 years receiving a PICC were included. Pre-and post-puncture variables were collected and a logistic regression was used to identify the independent factors associated with the risk of DVT.

RESULTS

The DVT prevalence was 1.8% (n = 213). The median length of PICC use was 15.3 days. The median age was 75 years (18; 107) and 52% were men, 53.5% were critically ill and 29.1% oncological patients. The most common indications for PICC's were intravenous antibiotics (79.1%). Notably, 91.5% of PICC showed a catheter-to-vein ratio of no more than 33%. The tip location method with intracavitary electrocardiogram was used in 43%. Most catheters (67.9%) were electively removed at the end of intravenous therapy. After adjusting for cancer profile ou chemotherapy, regression anaysis revealed that age (OR 1.011; 95% CI 1.002-1.020), previous DVT (OR 1.96; 95% CI 1.12-3.44) and obstruction of the device (OR 1.60; 95% CI 1.05-2.42) were independent factors associated with PICC-associated DVT, whereas the use of an anticoagulant regimen was a protective variable (OR 0.73; 95% CI 0.54-0.99).

CONCLUSION

PICC is a safe and suitable intravenous device for medium and long-term therapy, with low rates of DVT even in a cohort of critically ill and cancer patients.

Numerical Study on the Impact of Central Venous Catheter Placement on Blood Flow in the Cavo-Atrial Junction

An in silico study is performed to investigate fluid dynamic effects of central venous catheter (CVC) placement within patient-specific cavo-atrial junctions. Prior studies show the CVC infusing a liquid, but this study focuses on the placement without any liquid emerging from the CVC. A 7 or 15-French double-lumen CVC is placed virtually in two patient-specific models; the CVC tip location is altered to understand its effect on the venous flow field. Results show that the CVC impact is trivial on flow in the superior vena cava when the catheter-to-vein ratio ranges from 0.15 to 0.33. Results further demonstrate that when the CVC tip is directly in the right atrium, flow vortices in the right atrium result in elevated wall shear stress near the tip hole. A recirculation region characterizes a spatially variable flow field inside the CVC side hole. Furthermore, flow stagnation is present near the internal side hole corners but an elevated wall shear stress near the curvature of the side hole's exit. These results suggest that optimal CVC tip location is within the superior vena cava, so as to lower the potential for platelet activation due to elevated shear stresses and that CVC geometry and location depth in the central vein significantly influences the local CVC fluid dynamics. A thrombosis model also shows thrombus formation at the side hole and tip hole. After modifying the catheter design, the hemodynamics change, which alter thrombus formation. Future studies are warranted to study CVC design and placement location in an effort to minimize CVC-induced thrombosis incidence.

Severe ischemia after radial artery catheterization: A literature review of published cases

INTRODUCTION

Severe ischemia is a rare complication of radial artery catheterization (RAC). This study aims to summarize risk factors of RAC-elicited severe hand ischemia, preventive, and therapeutic management.

METHODS

Literature search was conducted in eight electronic English and Chinese databases to identify relevant published cases. Data of interest was extracted and analyzed.

RESULTS

Database search identified 28 articles reporting cases of 57 patients developing hand ischemia following RAC. Patients aged between 1 day and 88 years. The indications for RAC included surgery, shock, cardiac arrest, and Neonatal Intensive Care Unit (NICU) admission. Identified risk factors included pre-existing vascular diseases, hypotension, arterial anatomical abnormality or small diameter, vasoconstrictors, and catheter-related problems. Totally, 18 patients complained pain; 32 developed discoloration; 19 pulselessness; 3 paresthesia; 13 swolleness and 19 coldness. Eventually, 30 patients recovered well, but 20 patients unfortunately underwent digital amputation and three patients deceased due to non-RAC-related causes.

CONCLUSION

Severe hand ischemia following RAC is a rare complication, with the reported incidence of approximately 0.09%. There is no definite predictor for RAC-related hand ischemia, but patients with risk factors are prone to the occurrence of hand ischemia. It's vital to initiate early recognition and proactive strategies for a best practice RAC insertion.

Effects of positive airway pressure on basilic vein diameter and venous flow velocity in healthy volunteers

INTRODUCTION

The placement of vascular catheters of adequate size in accordance to catheter-to-vein ratio (CVR) recommendations represents one of the cornerstones of catheter-related upper vein thrombosis prevention. However there is scarcity of data on its effect on the venous dynamics of the basilic vein, a common site for long-term catheter placement. This study investigates the effects of the application of positive airway pressure on the diameter and blood flow velocity of basilic vein. We also measured the effects of under-armpit straps, a device commonly used to keep continuous positive airway pressure (CPAP) helmets in place.

METHODS

We enrolled 28 healthy volunteers. Basilic vein diameter and minimum/maximum blood flow velocity, according to respiratory venous flow oscillation, were measured by ultrasound on the midpoint of their dominant arm during spontaneous breathing and during breathing in a CPAP helmet with 10 cm H2O of airway pressure applied, with the helmet kept in place either through armpit straps or by tying the helmet to the bed.

RESULTS

The application of 10 cm H2O of positive airway pressure significantly increased basilic vein diameter by 0.9 ± 0.2 mm, while reducing minimum blood flow velocity by 1.8 ± 0.4 cm/s. These effects were amplified by the application of under armpit straps.

CONCLUSIONS

Breathing with positive airway pressure increases basilic vein diameter while reducing blood flow-velocity. This phenomenon might lead to an incorrect assessment of CVR, misleading the operator into choosing improperly large catheters.

Extravasation and infiltration: under-recognised complications of intravenous therapy

Occasionally, the administration of intravenous (IV) therapies can go wrong. Infiltration or extravasation is a complication when a drug or IV therapy leaks into the tissues surrounding the vascular access device. Extravasation can cause serious and often life-changing injuries. Extravasation is often associated with systemic anti-cancer therapy but non-chemotherapy drugs have been reported as having a greater risk of serious complications. This study outlines the first UK Infusion unit evaluation of the ivWatch infusion monitoring device which was undertaken from August 2023 to January 2024. Out of 2254 infusions monitored with ivWatch, the device prevented 122 cases of infiltration and extravasation from causing any harm to the patient, corresponding to a 5.4% 'check IV' notification rate.

Extravasation and infiltration: under-recognised complications of intravenous therapy

Occasionally, the administration of intravenous (IV) therapies can go wrong. Infiltration or extravasation is a complication when a drug or IV therapy leaks into the tissues surrounding the vascular access device. Extravasation can cause serious and often life-changing injuries. Extravasation is often associated with systemic anti-cancer therapy but non-chemotherapy drugs have been reported as having a greater risk of serious complications. This study outlines the first UK Infusion unit evaluation of the ivWatch infusion monitoring device which was undertaken from August 2023 to January 2024. Out of 2254 infusions monitored with ivWatch, the device prevented 122 cases of infiltration and extravasation from causing any harm to the patient, corresponding to a 5.4% 'check IV' notification rate.

10 best practice tips with radial arterial catheterization

Radial arterial catheters (RAC) are used extensively across critical care settings (Anesthesia, Intensive Care, Emergency Medicine) for continuous hemodynamic monitoring, allowing for immediate adjustments in vasopressor therapies and blood collection. Radial catheter failures are an ongoing significant issue for critical care clinicians with reported incidences at almost 25%. Common complications include loss of function, lack of blood return, poor quality waveforms and dislodgement, posing potential patient risks, and sudden loss of intra-arterial monitoring frequently requires prompt replacement. Contemporary research and technological improvements have highlighted several concepts to enhance the approach of RAC insertion and management while reducing immediate and late complications. The authors have prioritized the following 10 "best practice" aspects that may improve overall device function and reliability.

Predictors of ultrasound-guided peripheral intravenous catheter failure: A secondary analysis of existing trial data

OBJECTIVES

Ultrasound-guided (US) peripheral intravenous catheters (PIVC) have a high failure rate with many failing prior to completion of therapy. Risk factors associated with catheter failure are poorly delineated. This study aimed to assess risk factors related to catheter failure including patient, procedure, catheter, and vein characteristics to further elucidate which variables may impact catheter longevity.

METHODS

This was a secondary analysis using an existing trial dataset that primarily compared survival of two catheters: a standard long (SL) and an ultra-long (UL) US PIVC. Adult emergency room patients with difficult intravenous access at a tertiary care suburban academic center were study participants. Kaplan-Meier was employed to estimate the median catheter survival time. Cox regression univariable and multivariable analyses were used to evaluate the primary outcome of catheter survival.

RESULTS

Among 257 subjects, 63% of PIVCs survived until completion of therapy. In a multivariable Cox regression model, length of catheter in vein >2.75 cm (adjusted hazard ratio [aHR] 0.58, 95% confidence interval [CI] 0.37-0.90, p = 0.01) was associated with improved survival. First stick success decreased the risk of catheter failure (aHR 0.68, 95% CI 0.44-1.06, p = 0.09) but was not statistically significant. Factors associated with the increased risk of catheter failure included: depth of vein >1.2 cm (aHR 1.68, 95% CI 1.06-2.66, p = 0.03) and PIVC placement in right extremity (aHR 1.64, 95% CI 1.07-2.51, p = 0.02).

CONCLUSIONS

This study demonstrated that catheter length in vein (>2.75 cm) was associated with improved US PIVC survival highlighting the value of longer catheters in US PIVC survival. Choosing targets in the non-dominant extremity with shallower depths (⩽1.2 cm) may also increase catheter survival.

Programs and processes for advancing pediatric acute kidney support therapy in hospitalized and critically ill children: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference

Pediatric acute kidney support therapy (paKST) programs aim to reliably provide safe, effective, and timely extracorporeal supportive care for acutely and critically ill pediatric patients with acute kidney injury (AKI), fluid and electrolyte derangements, and/or toxin accumulation with a goal of improving both hospital-based and lifelong outcomes. Little is known about optimal ways to configure paKST teams and programs, pediatric-specific aspects of delivering high-quality paKST, strategies for transitioning from acute continuous modes of paKST to facilitate rehabilitation, or providing effective short- and long-term follow-up. As part of the 26th Acute Disease Quality Initiative Conference, the first to focus on a pediatric population, we summarize here the current state of knowledge in paKST programs and technology, identify key knowledge gaps in the field, and propose a framework for current best practices and future research in paKST.

Macro- and microscopic changes in veins with short-term central venous catheters: an observational autopsy study

BACKGROUND

Centrally inserted central catheters (CICCs) are indispensable in modern healthcare, but unfortunately, come with complications. Catheter-related thrombosis is a well-known complication reported to occur in 5-30% of patients with CICC. There is a paucity of studies that report the incidence of catheter-related thrombosis after the introduction of real-time ultrasound insertion guidance as clinical practice. This study aimed to demonstrate any pathological macro- or microscopic changes in the vein wall associated with CICCs.

METHODS

The study was approved by the Swedish Ethical Review Authority and was conducted at a large university hospital. The study included 12 patients with a short-term CICC who were subject to autopsies. Vessels with inserted catheters were macroscopically and microscopically examined.

RESULTS

In total, seven female and five male patients with a median age of 70 (interquartile range 63-76) were included. With one exception, all patients received routine thromboprophylaxis throughout the period with CICC. Most inserted CICCs were 9.5 French (54%) and were inserted in the internal jugular vein (92%). The median time with CICC was seven days (interquartile range 1.8-20). At autopsy, thrombi were observed in all cases (100%), macroscopically and microscopically, attached to the distal portion of the CICC and/or the adjacent vessel wall. Inflammatory changes in the vessel walls were seen in all cases, and varying degrees of fibrosis were demonstrated in eight cases (67%).

CONCLUSIONS

This autopsy study demonstrated that catheter-related thrombus formation with adjacent inflammatory and fibrotic vessel wall thickening was very common, despite a limited period of catheter use. The consequences of these findings are important, as thrombi may cause pulmonary embolism and possibly lead to catheter-related infections, and since inflammatory and fibrotic vessel wall thickening may evolve into chronic venous stenosis. Furthermore, the findings are a cause of concern, as CICCs are indispensable in modern healthcare and complications may be masked by the general disease that was the indication for CICC insertion.

Clinical experience with a chlorhexidine-coated PICC: A prospective, multicenter, observational study

INTRODUCTION

This study evaluated a chlorhexidine-coated peripherally inserted central catheter (PICC) and the incidence of associated complications within both inpatient and outpatient populations.

METHODS

This IRB-approved, multicenter, prospective observational study was performed at three large teaching hospitals in the US. All adults who required a PICC for ⩾14 days were considered. Patients were monitored throughout entire catheter dwell. Duplex venous ultrasounds were performed before insertion, after 10 to 14 days of dwell time, and upon removal. Data was collected from the hospital, outpatient clinic, and patient PICC diary records.

RESULTS

A total of 103 patients, 56% male, with mean BMI 29 ± 8.8, were enrolled. The majority (79%) of patients were from high-risk groups-cancer, infectious diseases, transplant, and trauma. Primary treatment indications were antibiotics (66.99%) and chemotherapy (25.24%). Double lumen PICCs (59.2%) were favored clinically, as was basilic vein placement (71.84%). Mean catheter dwell was 47.01 ± 25.82 days. Three (3, 2.9%) central line-associated bloodstream infections (CLABSI) were reported. Four patients (4.6%) reported symptomatic catheter-related thrombosis (CRT), confirmed with ultrasound. Three patients (3.4%) had ultrasound-confirmed fibroblastic sleeve (FS). Eight patients (9.2%) who entered the study with pre-existing superficial thrombosis, had complete resolution at the time of catheter removal. The incidence of CLABSI was 0.82/1000 days. The combined CRT and FS rate was 6.9%.

CONCLUSION

Based upon the observational findings of this study, chlorhexidine-coated PICC technology may be considered for use in patient populations who are at moderate to high-risk for catheter-related complications in both inpatient and outpatient settings.

The SIP protocol update: Eight strategies, incorporating Rapid Peripheral Vein Assessment (RaPeVA), to minimize complications associated with peripherally inserted central catheter insertion

Insertion of Peripherally Inserted Central Catheters (PICCs) is potentially associated with the risk of immediate/early adverse events, some of them minimal (repeated punctures) and some relevant (accidental arterial puncture or nerve-related injury). Several strategies adopted during the insertion process may minimize the risk of such events, including late complication risks such as infection, venous thrombosis, or catheter dislodgment and/or malposition. This paper describes an update version of the SIP protocol (Safe Insertion of PICCs), an insertion bundle which includes eight effective strategies that aims to minimize immediate, early, or late insertion-associated complications. These strategies include: preprocedural ultrasound assessment utilizing the RaPeVA (Rapid Peripheral Venous Assessment) protocol; appropriate skin antiseptic technique; choice of appropriate vein, adoption of the Zone Insertion Method™; clear identification of the median nerve and brachial artery; ultrasound-guided puncture; ultrasound-guided tip navigation; intra-procedural assessment of tip location; correct securement of the catheter, and appropriate protection of the exit site. This updated version of the SIP protocol includes several novelties based on the most recent evidence-based scientific literature on PICC insertion, such as the clinical relevance of the tunneling technique, the use of ultrasound for intra-procedural tip navigation and tip location, and the new technologies for the protection of the exit site (cyanoacrylate glue) and for the securement of the catheter (subcutaneous anchorage).

On-demand use of peripheral arterial catheters outside the Intensive Care Unit: Development and retrospective evaluation of an internal protocol for insertion and management

BACKGROUND

COVID-19 patients require frequent arterial blood gas analysis for the assessment of oxygenation status.

OBJECTIVE

The main objective of this research is to describe a dedicated protocol developed to standardize the insertion and management of peripheral Arterial Catheters (AC) for on-demand use, in the Emergency Department of "Maggiore" Hospital (Lodi, Italy).This strategy represents a valid alternative to repeated arterial punctures outside the intensive care unit.

METHODS

The crucial points of the protocol were defined: vessel selection criteria, device used, technique of insertion, choice of securement and dressing device, and procedures had been created for correct management.

RESULTS

During April and December 2020, 50 AC were inserted, two dislocations and one malfunction were observed. No major complications (Catheter Related Bloodstream Infection, thrombosis, bleeding, pseudoaneurysms, hematoma, artery occlusion - even temporary - and skin irritation) were observed.

CONCLUSIONS

To the authors knowledge, this is the first article describing the insertion and management of ACs for on-demand utilization outside the intensive care unit. The safe and effective use of this technique could be clinically relevant in patients requiring multiple ABG without need of invasive monitoring; it also allows the reduction of both artery sticks and workload of health care providers. However, clinical studies are needed to confirm the validity of the proposed treatment, especially the use of the most appropriate securement system and the most effective solution for locking catheters.

Incidence of asymptomatic catheter-related thrombosis in intensive care unit patients: a prospective cohort study

BACKGROUND

Catheter-related thrombosis (CRT) incidence, rate, and risk factors vary in literature due to differences in populations, catheters, diagnostic methods, and statistical approaches. The aim of this single-center, prospective, observational study was to assess incidence, incidence rate (IR), cumulative incidence, and risk factors by means of IR ratio (IRR) of asymptomatic CRT in a non-oncologic Intensive Care Unit (ICU) population. CRT development was assessed daily by means of ultrasound screening. The proportions of patients and catheters developing CRT and CRT incidence rates, expressed as the number of events per catheter-days (cd), were calculated. Kalbfleisch and Prentice's method was used to estimate the cumulative incidence of CRTs. Univariate and multivariable Poisson regression models were fitted to calculate IRR in risk factors analysis.

RESULTS

Fifty (25%, 95% CI 19-31) out of 203 included patients, and 52 (14%, 95% CI 11-18) out of 375 catheters inserted developed CRT [IR 17.7 (13.5-23.2) CRTs/1000*cd], after 5 [3-10] days from insertion. Forty-six CRTs (88%) were partial thrombosis. All CRTs remained asymptomatic. Obesity and ECMO support were patient-related protective factors [IRR 0.24 (0.10-0.60), p = 0.002 and 0.05 (0.01-0.50), p = 0.011, respectively]. The internal jugular vein had higher CRT IR than other sites [20.1 vs. 5.9 CRTs/1000*cd, IRR 4.22 (1.22-14.63), p = 0.023]. Pulmonary artery catheter and left-side cannulation were catheter-related risk factors [IRR 4.24 (2.00-9.00), p < 0.001 vs. central venous catheters; IRR 2.69 (1.45-4.98), p = 0.002 vs. right cannulation, respectively]. No statistically significant effect of the number of simultaneously inserted catheters [IRR 1.11 (0.64-1.94), p = 0.708] and of the catheterization length [IRR 1.09 (0.97-1.22), p = 0.155] was detected. The ICU length of stay was longer in CRT patients (20 [15-31] vs. 6 [4-14] days, p < 0.001), while no difference in mortality was observed.

CONCLUSIONS

CRTs are frequent but rarely symptomatic. This study suggests that obesity and ECMO are protective factors, while pulmonary artery catheter, internal jugular vein and left-side positioning are risk factors for CRT.

The clinical topography of peripherally inserted central catheter-related thrombosis in cancer patients: A prospective and longitudinal observational study based on ultrasound scans every two days

AIMS

To delineate the clinical topography of peripherally inserted central catheter (PICC)-related thrombosis in cancer patients.

BACKGROUND

Most of the clinical features of PICC-related thrombosis are based on a single follow-up, which is insufficient to reflect the full topography of a thrombosis.

DESIGN

This is an observational study conducted at West China Hospital, according to the STROBE guidelines.

METHODS

Cancer patients scheduled for PICC placement were potentially eligible; patients with contraindications to PICC placement or existing diseases affecting blood flow were excluded; and those who later withdrew or did not reply to our contact request during the follow-up period were eliminated from this study. Ultrasound was used to detect thrombosis from the insertion site, proximal insertion site, axillary vein to the subclavian vein once every two days for two weeks post insertion. The thrombosis and its involved venous segments, onset time and symptoms and signs were recorded.

RESULTS

Among the 173 included patients, 126 (72.8 %) were identified as having thrombosis. Specifically, 113 and 126 patients were identified as having thrombosis within the first three days and the first week post insertion, respectively. In the 126 patients, thrombosis occurred at the insertion site (72.8 %) concurrently with thrombosis at the proximal insertion site (n = 120, 69.4 %), thrombosis in the axillary vein (n = 94, 54.3 %), and/or thrombosis in the subclavian vein (n = 41, 23.7 %). The log-rank test demonstrated that thrombosis in these four venous segments decreased significantly from the distal to the proximal central vein (log-rank test = 117.128, P < .001). Of 31 patients (17.9 %) who presented symptomatic thrombosis, only five patients experienced obvious swelling in the upper arm, and the other 26 patients exhibited atypical symptoms, such as soreness, tightness, numbness, tingling, or other discomforts in the palm, arm, armpit, and/or shoulder. In some thrombotic cases, ultrasonic assessment of PICC-related thrombosis did not parallel clinical symptoms and signs.

CONCLUSION

PICC-related thrombosis is common and can occur very early post insertion in cancer patients, and most thromboses present atypical symptoms. More than half of the cases with thrombosis evaluated involve multiple venous segments, and the farther the venous segments are from the central vein, the higher the incidence of thrombosis tend to be and the earlier the onset time are.

RELEVANCE TO CLINICAL PRACTICE

The results highlight the importance that medical staff pay particular attention to patients with catheters in the first week post insertion and be alert to thrombosis presenting atypical symptoms while keeping in mind that clinical symptoms and signs are not reliable for diagnosing thrombosis.

CLINICAL REGESTRATION

Clinical Trials ChiCTR1900024890.

Identifying the impact of the Zone Insertion MethodTM (ZIMTM): A randomized controlled trial

BACKGROUND

In 2011, Dawson proposed the Zone Insertion MethodTM (ZIMTM) to identify the optimal peripherally inserted central catheters (PICCs) insertion site in the upper arm. However, data on the effectiveness and safety of the ZIMTM in guiding PICC placement in Chinese population is limited.

METHODS

In this randomized controlled trial, 120 cancer patients were randomly assigned to the upper portion of the red zone (RZ), the green zone (GZ) and the lower portion of the yellow zone (YZ) groups (at a 1:1:1 ratio). The aim was to compare the degree of patient comfort and the incidence of major PICC complications among the three insertion zones based on the ZIMTM in a Chinese Cancer Center. (Clinical Trials. Gov number, ChiCTR1900024111).

RESULTS

A total of 118 catheters were inserted in 118 patients (2 patients were lost to follow-up). After the 1-month follow-up, patients randomly assigned to the YZ group had a higher degree of comfort with a lower score than those assigned to the other two zone groups: 30.21±3.16 in the YZ group versus 31.65±2.51 in the RZ group and 31.59±2.92 in the GZ group (P=.046). The incidence of thrombosis (10/40, 25%) and occlusion (4/40, 10%) in the RZ, which were significantly higher than those in the other two zone groups (χ2 =7.368, P=.02; χ2 =5.778, P =.03), whereas the risk in the GZ group was similar to that in the YZ group. The incidence of contact dermatitis in the GZ group was significantly higher than that of the other two zone groups (χ2=12.873, P=.001).

CONCLUSIONS

This study found that the lower portion of YZ seems to be another suitable PICC insertion site for a higher degree of comfort and a lower risk of occlusion and thrombosis, which broadens the choice of PICC insertion sites in the upper arm for clinical practice.

Right heart thrombus in transit and peripherally inserted central catheters

Right heart thrombus in transit or "free-floating right heart thrombus" is defined as thrombus(i) arising from the deep veins that embolises to the right atrium or right ventricle before reaching the pulmonary vasculature. It is almost always associated with pulmonary thromboembolism and is a medical emergency with reported mortality rates of over 40%. We present two cases of right heart thrombus in transit with pulmonary thromboembolism resulting from venous thrombosis associated with peripherally inserted central catheters that were managed with different approaches. The cases highlight that clinicians should have a low threshold to utilise imaging modalities such as computerised tomography and transthoracic echocardiography when there is an untoward change in physiological parameters among patients with peripherally inserted central catheters, particularly those with risk factors for peripherally inserted central catheter associated venous thrombosis. Furthermore, procedural optimisation surrounding peripherally inserted central catheters, such as insertion technique and choice of lumen size, is underscored.

Contemporary Use of Ultrasonography in Acute Care Pediatrics

Use of ultrasonography by clinicians at the point of care has expanded widely and rapidly. Pediatric acute care providers now leverage this valuable tool to guide procedures, diagnose pathophysiologic processes, and inform time-sensitive decisions in sick and unstable children. However, the deployment of any new technology must be packaged with training, protocols, and safeguards to optimize safety for patients, providers, and institutions. As ultrasonography is increasingly incorporated into residency, fellowship, and even medical student curricula, it is important that educators and trainees are aware of the diversity of its clinical applications. This article aims to review the current state of point-of-care ultrasonography in acute care pediatrics, with an emphasis on the literature supporting the use of this important clinical tool.

The catheter-to-vein ratio at the tip level, not the catheter type, as a risk factor for a catheter failure. A retrospective comparative study of polyurethane midline and long peripheral catheters

BACKGROUND

In patients requiring a peripheral venous access for more than seven days, long peripheral catheters (LPCs) or midline catheters (MCs) are recommended. Since MCs and LPCs share many characteristics, studies comparing devices made of the same biomaterial are needed. Moreover, a catheter-to-vein ratio >45% at the insertion point has been recognized as a risk factor for catheter related complications, but no study investigated the effect of the catheter-to-vein ratio at the catheter tip level in peripheral venous devices.

OBJECTIVES

To compare the catheter failure risk between polyurethane MCs and LPCs, considering the effect of the catheter-to-vein ratio at the tip location.

METHODS

Retrospective cohort study. Adult patients having an expected need for a vascular access of more than 7 days and receiving either a polyurethane LPC or MC were included. The catheter uncomplicated indwelling time within 30 days was considered in survival analysis.

RESULTS

In a sample of 240 patients, the relative incidences of catheter failure were 5.13 and 3.40 cases for 1,000 catheter days for LPCs and MCs, respectively. In univariate Cox regression, MCs were associated to a statistically significant lower risk of catheter failure (HR 0.330; p = 0.048). After adjusting for other relevant conditions, a catheter-to-vein ratio >45% at the catheter tip location - not the catheter itself - was an independent predictor of a catheter failure (HR 6.762; p = 0.023).

CONCLUSIONS

The risk of catheter failure was strongly associated with a catheter-to-vein ratio > 45% at the catheter tip level, irrespective for having used a polyurethane LPC or MC.

A triple tunnel from the mid-calf to the femoral vein in patient with severe dementia

Achieving the ideal exit site is the new philosophy for complicated vascular access patients. Recent publications have described multiple venous access solutions such as tunneling to the scapular region, the chest to the arm, and from the femoral vein to the abdominal and patellar region. In the patients afflicted with delirium, dementia, or confusion even these sites may not be sufficient. The following case study illustrates a triple tunneled femoral catheter on a non-cooperative patient with inoperable endocarditis to be discharged and treated with long term antibiotics.

Factors affecting mechanical complications of central venous access devices in children

PURPOSE

Factors leading to mechanical complications following insertion of central venous access devices (CVADs) in children are poorly understood. We aimed to quantify the rates and elucidate the mechanisms of these complications.

METHODS

Retrospective (2016-2021) review of children (< 18 years old) receiving a CVAD. Data, reported as number of cases (%) and median (IQR), were analysed by Fisher's exact test, chi-squared test and logistic regression analysis.

RESULTS

In total, 317 CVADs (245 children) were inserted. Median age was 5.0 (8.9) years, with 116 (47%) females. There were 226 (71%) implantable port devices and 91 (29%) Hickman lines. Overall, 54 (17%) lines had a mechanical complication after 0.4 (0.83) years from insertion: fracture 19 (6%), CVAD migration 14 (4.4%), occlusion 14 (4.4%), port displacement 6 (1.9%), and skin tethering to port device 1 (0.3%). Younger age and lower weight were associated with higher risk of complications (p < 0.0001). Hickman lines had a higher incidence of complications compared to implantable port devices [24/91 (26.3%) vs 30/226 (13.3%); p = 0.008].

CONCLUSION

Mechanical complications occur in 17% of CVADs at a median of < 6 months after insertion. Risk factors include younger age and lower weight. Implantable port devices have a lower complications rate.

LEVEL OF EVIDENCE

Level 4: case-series with no comparison group.

Preventing radial arterial catheter failure in critical care - Factoring updated clinical strategies and techniques

Radial artery catheterization is a frequently performed procedure for critically ill patients. The correct function of arterial catheters is essential to provide accurate and continuous hemodynamic monitoring, facilitating intermittent blood sampling and helping to optimize the workload for critical care nurses and physicians. However, they are not without their own problems. This narrative practice review discusses several clinical aspects that are not frequently considered but may contribute to enhanced catheter functionality, less device-related failure and more acceptable dwell times. Ultrasound has demonstrated unequivocal efficacies and safety with the procedure, improving first attempt success rates with children, the obese or patients with unstable clinical vital signs and shock. Moreover, anatomic variations of the radial artery are not rare, and ultrasound-guided catheterization reduces the incidence of insertion-related complications such as hematoma, posterior wall puncture, intimal dissection, and radial nerve injury. Ultrasound guidance offers several immediate benefits by enhancing the most appropriate insertion techniques, allows for the correct catheter to vessel ratio measurements to be performed and reduces the angle of insertion, which may affect catheter failure due to inappropriate catheter length. A deeper and more proximal cannulation site at least 4 cm from wrist joint, avoiding the area of wrist flexion, reduces mechanical complications related to patient movements and may improve catheter functionality and dwell along with a better area for stabilization and securement.

A Single-Center Experience With Total Percutaneous Implantation of a Low-Profile Thoracic Aortic Stent-Graft

PURPOSE

To evaluate the safety and effectiveness of total percutaneous implantation of the Zenith Alpha Thoracic (ZTA) endograft in the treatment of diseases of the descending thoracic aorta.

MATERIALS AND METHODS

A retrospective cohort study of 56 consecutive patients undergoing total percutaneous ZTA implantation between 2018 and 2020 was performed in a single center. Patients' demographics, clinical characteristics, anatomical parameters, operative details, device features, and postoperative outcomes were assessed. The primary endpoint was ongoing clinical success. A Cox regression model was used to determine the predictive factors of worse postoperative outcomes.

RESULTS

Eighty-three ZTA endografts were implanted in 35 men and 21 women with a mean age of 69±11 years for the treatment of 26 degenerative aneurysms, 15 type B dissections, and 8 penetrating ulcers, among others. Primary technical success was 100%, with a 30-day ongoing clinical success rate of 94.6%. The 1-year ongoing clinical success rate was 91.1% (51 patients), and freedoms from all-cause mortality, type 1 and 3 endoleaks, and any unplanned reintervention were, respectively, 95.3%, 91.4%, and 88.2% at 1 year. During follow-up, there was one case of surgical conversion for an aorto-esophageal fistula. On the contrary, neither aneurysmal rupture nor significant aneurysmal expansion was recorded. Repair of ruptured thoracic aorta and a high ratio of sheath outer diameter to external iliac artery diameter were found to be independently associated with worse outcomes, with adjusted odds ratios of 4.4 [1.5-15.3] and 4.9 [1.1-23.9], respectively.

CONCLUSION

The outcomes of total percutaneous implantation of ZTA endograft show excellent primary technical success and favorable midterm ongoing clinical success. Factors associated with worse outcomes include the repair of ruptured aorta and a high sheath to access vessel ratio.

Patterns, appropriateness and outcomes of peripherally inserted central catheter use in Brazil: a multicentre study of 12 725 catheters

Background

Little is known about peripherally inserted central catheter (PICC) use, appropriateness and device outcomes in Brazil.

Methods

We conducted an observational, prospective, cohort study spanning 16 Brazilian hospitals from October 2018 to August 2020. Patients ≥18 years receiving a PICC were included. PICC placement variables were abstracted from medical records. PICC-related major (deep vein thrombosis (DVT), central line-associated bloodstream infection (CLABSI) and catheter occlusion) and minor complications were collected. Appropriateness was evaluated using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Devices were considered inappropriate if they were in place for <5 days, were multi-lumen, and/or were placed in patients with a creatinine >2.0 mg/dL. PICCs considered appropriate met none of these criteria. Mixed-effects logistic regression models adjusting for patient-level and hospital-level characteristics assessed the association between appropriateness and major complications.

Results

Data from 12 725 PICCs were included. Mean patient age was 66.4±19 years and 51.0% were female. The most common indications for PICCs were intravenous antibiotics (81.1%) and difficult access (62.7%). Most PICCs (72.2%) were placed under ultrasound guidance. The prevalence of complications was low: CLABSI (0.9%); catheter-related DVT (1.0%) and reversible occlusion (2.5%). Of the 12 725 devices included, a total of 7935 (62.3%) PICCs were inappropriate according to MAGIC. With respect to individual metrics for appropriateness, 17.0% were placed for <5 days, 60.8% were multi-lumen and 11.3% were in patients with creatinine >2.0 mg/dL. After adjusting for patient and hospital-level characteristics, multi-lumen PICCs considered inappropriate were associated with greater odds of major complications (OR 2.54, 95% CI 1.61 to 4.02).

Conclusions

Use of PICCs in Brazilian hospitals appears to be safe and comparable with North America. However, opportunities to improve appropriateness remain. Future studies examining barriers and facilitators to improving device use in Brazil would be welcomed.

Ultrasound-Guided Peripherally Inserted Central Catheter Placement in Extremely Low Birth Weight Neonates

Extremely low birth weight (ELBW), <1,000 g, neonates require central venous access for their growth, development, and survival. Peripherally inserted central catheters (PICCs) provide such access and reduce the risks associated with other types of central venous catheters. While the use of ultrasound (US) to guide PICC placement further reduces these risks, this technology has not been integrated into neonatal practice. The purpose of this case study is to describe US-guided PICC placement in 2 ELBW neonates. PICCs were placed in 2 patients weighing 505 g and 800 g, respectively, utilizing US guidance where the practitioner was unable to identify veins using traditional methods (e.g., palpation, landmarks, transillumination, or infrared device). PICC placement utilizing US guidance in ELBW neonates is a safe and effective technique that improves outcomes, prevents complications, and promotes vessel preservation in this vulnerable population. It is essential that this technique is integrated into neonatal practice.

Novel use of a midline catheter for therapeutic and donor apheresis in children and adults

BACKGROUND

Apheresis procedures require adequate vascular access to achieve optimal inlet flow rates. While central lines provide such access, their placement and use are associated with risks; some of these risks are minimized if peripheral intravenous access can be established. However, peripheral intravenous access is associated with challenges in the pediatric setting. Research indicates that midline catheters reduce the use of CVADs and their associated risks. The use of midline catheters for apheresis has been reported recently in adults, but no studies have been published on their use in children. Thus, the purpose of this study was to evaluate the use of midline catheters for apheresis in the pediatric setting.

METHODS

A retrospective observational study was conducted to evaluate the safety and efficacy of midline catheters in subjects who underwent apheresis at a pediatric hospital from April 2018 to August 2020. Demographic data, clinical data (diagnosis, procedure, catheter size, body mass), and outcome data (inlet flow rate, total blood volume [TBV] processed, procedure time, and cell counts) were collected.

RESULTS

Eighteen subjects received a total of 100 midline catheters for 73 apheresis procedures. Inlet flow rates ranged from 45 to 80 mL/min, TBV ranged from 2872 to 20 000 mL, and procedure time ranged from 1.25 to 7 hours. Inlet flow rates met or exceeded the recommended inlet flow rates for apheresis in children and adults (P < .0001). No adverse events occurred.

CONCLUSION

Midline catheters provide safe and effective vascular access for apheresis. Future research should include younger patients with lower body mass.

Long-Term Results of a Standard Algorithm for Intravenous Port Implantation

Intravenous ports serve as vascular access and are indispensable in cancer treatment. Most studies are not based on a systematic and standardized approach. Hence, the aim of this study was to demonstrate long-term results of port implantation following a standard algorithm. A total of 2950 patients who underwent intravenous port implantation between March 2012 and December 2018 were included. Data of patients managed following a standard algorithm were analyzed for safety and long-term outcomes. The cephalic vein was the predominant choice of entry vessel. In female patients, wire assistance without use of puncture sheath was less likely and echo-guided puncture via internal jugular vein (IJV) with use of puncture sheath was more likely to be performed, compared to male patients (p < 0.0001). The procedure-related complication rate was 0.07%, and no pneumothorax, hematoma, catheter kinking, catheter fracture, or pocket erosion was reported. Catheter implantations by echo-guided puncture via IJV notably declined from 4.67% to 0.99% (p = 0.027). Mean operative time gradually declined from 37.88 min in 2012 to 23.20 min in 2018. The proposed standard algorithm for port implantation reduced the need for IJV echo-guided approach and eliminated procedure-related catastrophic complications. In addition, it shortened operative time and demonstrated good functional results.

Comparison of peripherally inserted central catheters and totally implanted venous access devices as chemotherapy delivery routes in oncology patients: A retrospective cohort study

This study aimed to evaluate peripherally inserted central catheters (PICCs) and totally implanted venous access devices (TIVADs) as chemotherapy delivery routes. From May 2016 to April 2019, patients with malignancies who had PICCs or TIVADs inserted for chemotherapy were enrolled. We reviewed the patients' medical records for information concerning demographics, comorbidities, catheter-related complications, and catheter -service days. All patients included in both groups were also assessed for complication-free catheter survival and completion rates of chemotherapy. A total of 467 catheter insertions (185 PICCs and 282 TIVADs) were included in this study. The PICCs were associated with a higher rate of complication-related catheter removal than TIVADs (hazard ratio, 6.5954; 95% confidence interval, 2.394-18.168; p<0.001). The completion of chemotherapy was observed in 77 (41.6%) patients with PICCs and 128 (45.4%) with TIVADs (p = 0.442). The mean duration of catheter service-days was shorter for the patients in the PICC group who completed chemotherapy than those in the TIVAD group (101.3 ± 93.2 vs 245.3 ± 115.9, respectively, p < 0.001). Although PICC was an independent risk factor for complication-related catheter removal, there was no difference in the chemotherapy completion rate between the groups. Therefore, PICCs need to be considered preferentially in patients who require a chemotherapy delivery route for short-term chemotherapy.

Long-term IV access in paediatrics - why, what, where, who and how

Establishment of long-term central venous access imposes the risk of procedural adverse events (air embolism, pneumothorax, accidental arterial cannulation of the great vessels, tricuspid valve damage and cardiac tamponade) as well as the risk of increased morbidity and mortality due to catheter related blood stream infections, vessel stenosis, deep vein thrombosis and the often high risk anaesthetic management of syndromic children. This narrative review aims to provide a historical and clinical background for the development and use of CVADs (central venous access devices), origin and management of the most common complications (catheter related thrombosis, infections and persistent withdrawal occlusion) and present the reader with an update on the "why, what, where, who and how" in paediatric long-term central venous access. Finally, we will present the reader with a clinical method for applying a retrograde inserted tunnelled and cuffed catheter using the left brachiocephalic vein access.

Ultrasound-guided percutaneous brachiocephalic vein cannulation for ventriculoatrial shunt placement in a child

OBJECTIVE

As far as the ventriculoatrial shunt placement in children is concerned, the percutaneous approach to the internal jugular vein under ultrasonographic control has been hitherto strongly recommended. Unfortunately, children still represent a challenge, having them peculiar characteristics for which the internal jugular vein cannulation shows some disadvantages.

METHODS

In this manuscript, we describe a percutaneous placement of ventriculoatrial shunt via right brachiocephalic vein under intraoperative ultrasonographic control.

CONCLUSIONS

Brachiocephalic vein cannulation in surgery provides notable advantages in paediatric population and it may be considered as the first choice in younger children.