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D'Andrea V, Pittiruti M, Prontera G, Vento G, Barone G. The SIECC protocol: A novel insertion bundle to minimize the complications related to epicutaneo-cava catheters in neonates. J Vasc Access 2024:11297298241239699. [PMID: 38641817 DOI: 10.1177/11297298241239699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024] Open
Abstract
Epicutaneo-cava catheters are the most widely used central venous catheters in the neonate, but their insertion and management are potentially associated with several complications, both during placement (failure to proceed with the catheter, primary malposition, etc.) and during maintenance (infection, venous thrombosis, catheter dislocation, secondary malposition, etc.). Recent studies have identified methods and techniques that may be effective in minimizing the risk of most of these complications. This paper proposes a structured, sequential insertion bundle-nicknamed "the SIECC protocol" (SIECC = Safe Insertion of Epicutaneo-Cava Catheters)-which includes seven evidence-based strategies which have been proven to increase the safety, effectiveness, and cost-effectiveness of the procedure.
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Affiliation(s)
- Vito D'Andrea
- Neonatal Intensive Care Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Lazio, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Lazio, Italy
| | - Giorgia Prontera
- Neonatal Intensive Care Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Lazio, Italy
| | - Gianni Vento
- Neonatal Intensive Care Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Lazio, Italy
| | - Giovanni Barone
- Neonatal Intensive Care Unit, Infermi Hospital, AUSL della Romagna, Rimini, Emilia-Romagna, Italy
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Barone G, Pittiruti M, Prontera G, Ancora G, D'Andrea V. A novel neonatal protocol for Safe Insertion of Umbilical Venous Catheters (SIUVeC): Minimizing complications in placement and management. J Vasc Access 2024:11297298241236220. [PMID: 38436297 DOI: 10.1177/11297298241236220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
Insertion of umbilical venous catheters is a common procedure in neonatal intensive care. Though sometimes lifesaving, this maneuver is potentially associated with early and late complications, some of which may be severe and even life threatening (catheter malposition, hepatic lesions, venous thrombosis, pericardial effusion, etc.). The recent literature suggests several operative strategies that, if adopted systematically, may significantly reduce the incidence of both early and late catheter related complications. This paper describes a standardized protocol (Safe Insertion Umbilical Venous Catheter = SIUVeC) which incorporates such novel strategies, with the goal of minimizing the complications related to this procedure.
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Affiliation(s)
- Giovanni Barone
- Neonatal Intensive Care Unit, Infermi Hospital, AUSL della Romagna, Rimini, Emilia Romagna, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Lazio, Italy
| | - Giorgia Prontera
- Neonatal Intensive Care Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Lazio, Italy
| | - Gina Ancora
- Neonatal Intensive Care Unit, Infermi Hospital, AUSL della Romagna, Rimini, Emilia Romagna, Italy
| | - Vito D'Andrea
- Neonatal Intensive Care Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Lazio, Italy
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Pittiruti M, Bilancia A, Ortiz Miluy G, D'Arrigo S. A comparison between two radiological criteria for verifying tip location of central venous catheters. J Vasc Access 2024; 25:551-556. [PMID: 36203365 DOI: 10.1177/11297298221126818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Current guidelines recommend intraprocedural methods-such as Intra-Cavitary ECG (IC-ECG) and echocardiography-for verifying the location of the tip of central venous catheters. Nonetheless, there are clinical conditions which may require to verify tip location by less accurate methods such as Chest X-Ray (CXR). We have compared the feasibility and accuracy of two radiological methods for tip location-the Sweet Spot Criterion (SSC) and the Carina Criterion (CC)-using IC-ECG as reference. METHODS In this retrospective multicenter study, we reviewed the radiology databases of three hospitals, examining all CXRs performed on patients after insertion of Peripherally Inserted Central Catheters (PICCs), as long as the tip location had been successfully performed during the procedure by IC-ECG. Tip location was verified using SSC and CC, comparing the two methods in terms of feasibility and accuracy. RESULTS We reviewed the CXR of 1116 PICCs successfully inserted by IC-ECG. CC was not feasible in 0.5% (impossible visualization of the carina) and difficult in 1.5%; in 97.7% of cases, the position of the tip was adequate (1-5 cm below the carina), in 0.6% too high (<1 cm), in 1.2% too low (6-9 cm). On the other hand, because of unclear visualization of radiological landmarks, SSC was not feasible in 0.9% and difficult in 10.5%; though, according to SSC the tip location was always acceptable (in 94.2% the tip was in the middle of the spot, in 2.5% close to the superior border, and in 2.3% close to the inferior border); no tip was visualized outside of the spot. CONCLUSION CC and SSC were similar in terms of feasibility (99.5% vs 99.1%) and accuracy (98.1% vs 100%), though CC was subjectively perceived to be easier and more rapid to perform.
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Affiliation(s)
- Mauro Pittiruti
- Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | | | | | - Sonia D'Arrigo
- Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
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D'Andrea V, Prontera G, Pinna G, Cota F, Fattore S, Costa S, Migliorato M, Barone G, Pittiruti M, Vento G. Umbilical venous catheter: focus on proper indication and proper securement. J Pediatr 2024; 266:113884. [PMID: 38128718 DOI: 10.1016/j.jpeds.2023.113884] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/17/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Vito D'Andrea
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy; Neonatal Intensive Care Unit, Maternal-Fetal Department, "S. Camillo-Forlanini" Hospital, Rome, Italy
| | - Giorgia Prontera
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy; Neonatal Intensive Care Unit, Maternal-Fetal Department, "S. Camillo-Forlanini" Hospital, Rome, Italy
| | - Giovanni Pinna
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy; Neonatal Intensive Care Unit, Maternal-Fetal Department, "S. Camillo-Forlanini" Hospital, Rome, Italy
| | - Francesco Cota
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy; Neonatal Intensive Care Unit, Maternal-Fetal Department, "S. Camillo-Forlanini" Hospital, Rome, Italy
| | - Simona Fattore
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy; Neonatal Intensive Care Unit, Maternal-Fetal Department, "S. Camillo-Forlanini" Hospital, Rome, Italy
| | - Simonetta Costa
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy; Neonatal Intensive Care Unit, Maternal-Fetal Department, "S. Camillo-Forlanini" Hospital, Rome, Italy
| | - Martina Migliorato
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy; Neonatal Intensive Care Unit, Maternal-Fetal Department, "S. Camillo-Forlanini" Hospital, Rome, Italy
| | - Giovanni Barone
- Neonatal Intensive Care Unit, Infermi Hospital, Rimini, AUSL Romagna, Rimini, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Gemelli, Rome, Italy
| | - Giovanni Vento
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
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D'Arrigo S, Emoli A, Marche B, Pittiruti M. A new pressure-based device for tip navigation and tip location during central venous catheterization: A prospective clinical study on a cohort of 136 adult patients. J Vasc Access 2024; 25:526-530. [PMID: 36114632 DOI: 10.1177/11297298221122092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Abstract
INTRODUCTION According to current guidelines, tip location of peripherally inserted central catheters (PICCs) should be verified during insertion, preferably using non-invasive methods such as intracavitary ECG (IC-ECG) or echocardiography. An interesting new option is represented by a new pressure-based device, the CatFinder System (CFS), which might be theoretically useful also for tip navigation. METHODS We planned a single-center, prospective, non-randomized trial on adult patients requiring PICC insertion, using simultaneously CFS and IC-ECG, with the purpose of verifying the applicability, feasibility, safety, and accuracy of CFS for intra-procedural tip location. Patients with known ECG abnormalities or cardiac diseases of any type were excluded. The ability of CFS to assess wrong directions of the catheter during insertion (tip navigation) was evaluated by comparison with ultrasound scan. RESULTS Out of 136 enrolled adult patients, CFS was found to be applicable in 131 cases (five cases were excluded because of ECG abnormalities) and feasible in 111 cases (in 20 cases, tip location by CFS could not be carried out because of technical issues). There were no complications directly or indirectly related to the CFS maneuvers. Using IC-ECG as a comparison, 87 tips placed by CFS were within 2 cm from the target, 17 were >2 cm from target. In seven cases, CFS was able to detect a wrong direction (to the ipsilateral internal jugular vein), as confirmed by ultrasound. CONCLUSION Applicability of CFS in patients with sinus rhythm was 96.3%, feasibility was 84.7%, and safety was 100%. If compared to IC-ECG, accuracy was 83.6% (accepting an error <2 cm) and 96.1% (for an error <3 cm). Unacceptable tip positions (>3 cm) were 3.8% (the tip was too high inside the SVC). This study confirms a possible future role of CFS for intra-procedural tip location and tip navigation, though its use cannot be currently recommended.
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Affiliation(s)
- Sonia D'Arrigo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Emoli
- Department of Oncology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bruno Marche
- Department of Hematology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Annetta MG, Celentano D, Zumstein L, Attinà G, Ruggiero A, Conti G, Pittiruti M. Catheter-related complications in onco-hematologic children: A retrospective clinical study on 227 central venous access devices. J Vasc Access 2024; 25:512-518. [PMID: 36113076 DOI: 10.1177/11297298221122128] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND The use of central venous access devices (CVADs) is of paramount importance to safely deliver antiblastic and support therapies in children with cancer. Though, in pediatric patients, as much as in adults, CVADs are potentially associated with severe complications which may result in unscheduled interruption of therapy, hospitalization, increased morbidity/mortality, and increased cost of care. METHODS We have reviewed retrospectively our experience with CVADs in children with solid tumors and hematologic diseases, with the purpose of verifying if the adoption of well-defined insertion and maintenance bundles might be effective in reducing catheter-related complications, and in particular catheter-related thrombosis. RESULTS A total of 227 CVADs were analyzed: 175 peripherally inserted central catheters (PICCs), 50 centrally inserted central catheters (CICCs), and 2 femorally inserted central catheters. All CVADs were non-valved, non-cuffed power injectable polyurethane catheters; 81% were tunneled. Median dwelling time of CVADs was 172 days, for a total number of 39,044 catheter days. A very low incidence of both symptomatic catheter-related thrombosis (0.9%) and catheter-related blood stream infection (0.56 episodes per 1000 catheter days) was found. Unscheduled removal or guidewire replacement because of mechanic complications occurred in 15.7% of CVADs. There was no difference in terms of complications between PICCs and CICCs or between tunneled and non-tunneled catheters. CONCLUSIONS Our experience with CVADs in oncologic and hematologic children suggests that catheter-related complications may be minimized by the adoption of appropriate insertion and maintenance bundles.
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Affiliation(s)
- Maria Giuseppina Annetta
- Department of Anesthesia and Intensive Care, Catholic University Hospital "A.Gemelli," Rome, Italy
| | - Davide Celentano
- Department of Oncology, Catholic University Hospital "A.Gemelli," Rome, Italy
| | - Lucrezia Zumstein
- Department of Pediatric Oncology, Catholic University Hospital "A.Gemelli," Rome, Italy
| | - Giorgio Attinà
- Department of Pediatric Oncology, Catholic University Hospital "A.Gemelli," Rome, Italy
| | - Antonio Ruggiero
- Department of Pediatric Oncology, Catholic University Hospital "A.Gemelli," Rome, Italy
| | - Giorgio Conti
- Department of Anesthesia and Intensive Care, Catholic University Hospital "A.Gemelli," Rome, Italy
| | - Mauro Pittiruti
- Department of Surgery, Catholic University Hospital "A.Gemelli," Rome, Italy
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Annetta MG, Marche B, Giarretta I, Pittiruti M. Applicability and feasibility of intraprocedural tip location of femorally inserted central catheters by transhepatic ultrasound visualization of the inferior vena cava in adult patients. J Vasc Access 2024; 25:651-657. [PMID: 36765466 DOI: 10.1177/11297298231153979] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND The ideal intraprocedural method for tip location during insertion of femorally inserted central catheters (FICCs) is still a matter of debate. When the catheter tip is meant to be in the right atrium or in the supradiaphragmatic inferior vena cava (IVC), tip location by either intracavitary electrocardiography or transthoracic echocardiography may be accurate and easy to perform. When the catheter tip is planned to be placed in the subdiaphragmatic IVC, fluoroscopy-though inaccurate and unsafe-has been regarded as the only option for intraprocedural tip location. METHODS We have investigated prospectively the applicability and feasibility of transhepatic ultrasound as intraprocedural method for assessing the location of the catheter tip in the subdiaphragmatic tract of IVC, during FICC insertion. RESULTS We enrolled 169 consecutive patients undergoing FICC insertion by ultrasound guided puncture of the superficial femoral vein. In 165 out of 169 patients, the subdiaphragmatic IVC was visualized by the transhepatic ultrasound view. In all cases of IVC visualization, the catheter tip could be identified by ultrasound, either directly (direct evidence of the tip inside the vein) or indirectly (enhanced visualization of the tip after "bubble test"). There was no immediate or early complication, and very few late complications. CONCLUSION The intraprocedural method of tip location of FICCs by transhepatic ultrasound was applicable in 97.6% of cases and feasible in 100%. When the position of the catheter tip is planned to be in the subdiaphragmatic IVC, this method of tip location is accurate, safe, and inexpensive, and should be considered as an alternative to fluoroscopy.
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Affiliation(s)
| | - Bruno Marche
- Vascular Access Team, Fondazione Policlinico Universitario "A.Gemelli," Roma, Italy
| | - Igor Giarretta
- Department of Emergency of High-Specialty and Medical Center, ASST-Settelaghi, Varese, Italy
| | - Mauro Pittiruti
- Vascular Access Team, Fondazione Policlinico Universitario "A.Gemelli," Roma, Italy
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Pittiruti M, Annetta MG, D'andrea V. Point-of-care ultrasound for vascular access in neonates and children. Eur J Pediatr 2024; 183:1073-1078. [PMID: 38117353 DOI: 10.1007/s00431-023-05378-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/06/2023] [Accepted: 12/09/2023] [Indexed: 12/21/2023]
Abstract
Ultrasound plays a major role in neonatal/pediatric vascular access, both for venous access and for arterial access, not only just for the insertion of intravascular catheters, but also for many other issues related to this type of maneuver. This "global use of ultrasound" includes a systematic and consistent adoption of this technology for several steps of vascular access: (a) the pre-procedural assessment/evaluation of the vessels, (b) the ultrasound-guided puncture and cannulation of arteries and veins, (c) the real-time diagnosis of immediate, puncture-related complications, (d) the so-called "tip navigation" (i.e., real-time intra-procedural assessment of the direction and trajectory of the guidewire and/or of the catheter inside the vasculature), (e) the so-called "tip location" (i.e., intra-procedural or post-procedural assessment of the proper position of the tip of the catheter), and (f) the early diagnosis and/or management of most non-infective late complications. CONCLUSION Therefore, any vascular access expert (nurse or physicians) should have documented competency in the use of ultrasound. This knowledge should include the use of ultrasound for assessment of vessels, for catheter insertion, for proper placement of the tip, and for real-time detection of complications. WHAT IS KNOWN • Ultrasound is obviously useful for vascular access procedures in neonates and children. WHAT IS NEW • Recent evidence suggests that ultrasound is useful for many purposes in the field of vascular access (preprocedural scan, ultrasound-guided puncture, tip navigation, tip location, diagnosis of most non-infective complications). • Recent evidence also suggests that radiological methods no longer play any role in the insertion of vascular accesses in neonates and children.
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Affiliation(s)
- Mauro Pittiruti
- Dept. of Surgery, Policlinico Universitario 'A.Gemelli', Largo Gemelli 8, 00168, Rome, Italy.
| | | | - Vito D'andrea
- Neonatal Intensive Care Unit, Policlinico Universitario 'A.Gemelli', Rome, Italy
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Scarano M, D'Arrigo S, De Letteriis S, Grasso S, Pittiruti M, Scoppettuolo G. Risk of thrombophlebitis associated with continuous peripheral infusion of vancomycin: The effect of dilution. J Vasc Access 2024; 25:107-112. [PMID: 35608270 DOI: 10.1177/11297298221095778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Although several guidelines recommend that prolonged administration of vancomycin should be preferably carried out by a central venous access, vancomycin is often given peripherally. Whether such risk may be affected by different modalities of administration in terms of dilution and time of infusion, it is a matter of controversy. METHODS This single-center prospective study enrolled all consecutive patients requiring prolonged intravenous infusion of vancomycin (1 g/day) using long peripheral cannula "mini-midline." Patients were randomized in study group (4 mg/ml) and control group (20 mg/ml). All patients were systematically evaluated every 24 h by the Visual Exit-Site Score and a daily ultrasound scan of the veins of the arm. RESULTS The daily ultrasound evaluation showed venous thrombosis at the distal tip of the cannula in all patients, in both groups. After this finding in the first 14 patients, the study was interrupted. All thromboses were completely asymptomatic and occurred in absence of any sign of catheter malfunction. The onset of thrombosis was significantly earlier in the control group (ranging from 24 to 48 h) than in the study group (ranging from 48 to 96 h), with an average of 30 ± 11 versus 68 ± 16 h (p < 0.001). CONCLUSION Continuous intravenous infusion of vancomycin should be preferably delivered by a central venous access, as largely recommended by current guidelines, since peripheral infusion is inevitably associated with venous thrombosis, independently from the type of peripheral venous access device adopted (short peripheral cannula vs long peripheral cannula) and from the extent of dilution.
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Affiliation(s)
- Marianna Scarano
- Department of Anesthesia and Intensive Care 2 "A. Brienza," A.O.U. Policlinico "Giovanni XXIII," Bari, Italy
| | - Sonia D'Arrigo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Lazio, Italy
| | - Sestilio De Letteriis
- Department of Anesthesia and Intensive Care 2 "A. Brienza," A.O.U. Policlinico "Giovanni XXIII," Bari, Italy
| | - Salvatore Grasso
- Department of Anesthesia and Intensive Care 2 "A. Brienza," A.O.U. Policlinico "Giovanni XXIII," Bari, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giancarlo Scoppettuolo
- Department of Infective Diseases, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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D'Andrea V, Prontera G, Pezza L, Barone G, Vento G, Pittiruti M. Rapid Superficial Vein Assessment (RaSuVA): A pre-procedural systematic evaluation of superficial veins to optimize venous catheterization in neonates. J Vasc Access 2024; 25:303-307. [PMID: 35593484 DOI: 10.1177/11297298221098481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Placement of peripheral intra-venous cannulas and epicutaneo-caval catheters is routinely performed in in Neonatal Intensive Care Unit (NICU), and both devices require visible superficial veins easy to cannulate. NICU patients are intrinsically characterized by poor and fragile vein asset, so that puncture and cannulation of superficial veins is often a challenge even for trained clinicians and cannulation frequently results in a stressful, painful, difficult procedure. METHODS AND RESULTS Rapid Superficial Vein Assessment is meant to offer a systematic pre-procedural evaluation of all superficial veins of the newborn, so to allow a rational choice of the best insertion site, tailored on the single patient, and optimized for the specific type of venous access device. The superficial veins are examined systematically, both with and without NIR technology, exploring seven skin areas in the following order: (1) medial malleolus, (2) lateral malleolus, (3) retro-popliteal fossa, (4) back of the hand and wrist, (5) antecubital fossa, (6) anterior scalp surface, and (7) posterior scalp surface. CONCLUSIONS The aim of the protocol is to increase the first attempt success rate and reduce the duration of the procedure, the number of attempts for single patient and possibly to limit complications, stress, and pain in neonates.
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Affiliation(s)
- Vito D'Andrea
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giorgia Prontera
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucilla Pezza
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Barone
- Neonatal Intensive Care Unit, Infermi Hospital, Rimini, Italy
| | - Giovanni Vento
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Brescia F, Pittiruti M, Spencer TR, Dawson RB. The SIP protocol update: Eight strategies, incorporating Rapid Peripheral Vein Assessment (RaPeVA), to minimize complications associated with peripherally inserted central catheter insertion. J Vasc Access 2024; 25:5-13. [PMID: 35633065 PMCID: PMC10845830 DOI: 10.1177/11297298221099838] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/21/2022] [Indexed: 11/15/2022] Open
Abstract
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).
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Affiliation(s)
- Fabrizio Brescia
- Unit of Anesthesia and Intensive Care, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario “A.Gemelli,” IRCCS, Rome, Italy
| | | | - Robert B Dawson
- Hospital Medicine and Vascular Access, Catholic Medical Center – Upper Connecticut Valley Hospital, Colebrook, NH, USA
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Bolis D, D'Arrigo S, Bartesaghi A, Panzeri C, Pelegalli P, Steffanoni A, Scoppettuolo G, Pittiruti M. Prospective clinical study on the incidence of catheter-related complications in a neurological intensive care unit: 4 years of experience. J Vasc Access 2024; 25:100-106. [PMID: 35603516 DOI: 10.1177/11297298221097267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Over the past decades, significant efforts have been made to reduce early and late catheter-related complications in critically ill patients, using approaches based on bundles of evidence-based interventions. METHODS In this prospective clinical study, the authors evaluated the incidence of catheter-related complications in their neuro-intensive care unit during a 4-year period, adopting systematically the GAVeCeLT bundles for the insertion and management of all central venous access devices: centrally inserted central catheters (CICCs), peripherally inserted central catheters (PICCs) and femorally inserted central catheters (FICCs). All early/immediate and late complications were recorded. RESULTS On 486 central lines (328 CICCs, 149 PICCs and 9 FICCs), the only clinically relevant early/immediate complication was primary tip malposition (1%). In regards late infective complications, the authors did not record any case of catheter-related bloodstream infection; though, they observed one case of central line associated blood stream infection (one CICC; 0.14/1000 catheter days), and 15 cases of catheter colonization (12 CICCs and 3 PICCs; 2.09 episodes/1000 catheter days). Late non-infective complications were few: 14 accidental dislodgments (2.9%), 18 irreversible lumen occlusions (3.7%), and no episodes of symptomatic catheter-related thrombosis or tip migration. CONCLUSION The systematic adoption of the GAVeCeLT bundles for CVAD insertion and maintenance was associated with a minimization of catheter-related complications. The strict adherence to the recommendations included in these bundles was the major determinant for clinical success.
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Affiliation(s)
- Denise Bolis
- Department of Neurosciences, Ospedale Alessandro Manzoni-ASST, Lecco, Italy
| | - Sonia D'Arrigo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Cristina Panzeri
- Department of Neurosciences, Ospedale Alessandro Manzoni-ASST, Lecco, Italy
| | - Paola Pelegalli
- Department of Neurosciences, Ospedale Alessandro Manzoni-ASST, Lecco, Italy
| | - Alberto Steffanoni
- Department of Neurosciences, Ospedale Alessandro Manzoni-ASST, Lecco, Italy
| | - Giancarlo Scoppettuolo
- Department of Infective Diseases, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Abstract
In the past 5 years, non-dialysis femoral venous access has changed in terms of indications, techniques of insertion, and expected incidence of complications. To the traditional non-emergency indication for femoral catheters-obstruction of the superior vena cava-many other indications have been added, both in intensive and non-intensive care. The insertion technique has evolved, thanks to ultrasound guided venipuncture, tunneling, and ultrasound based intraprocedural tip location. Insertion of femorally inserted central catheters may be today regarded as a procedure with an extremely low intraprocedural and post-procedural risk. The risk of infection is reduced by the possibility of the exit site at mid-thigh, by the use of cyanoacrylate glue for sealing the exit site, and by appropriate intraprocedural strategies of infection prevention. The risk of catheter-related thrombosis is low, due to several concomitant strategies: a proper match between vein diameter and catheter caliber; an accurate intraprocedural assessment of tip location by ultrasound and/or intracavitary ECG; the consistent use of ultrasound guided venipuncture and micro-introducer kits; an adequate stabilization of the catheter at the exit site. The risk of mechanical complications and the risk of lumen occlusion are minimized when using polyurethane, power injectable catheters. All these novelties have brought a revolution in the field of femoral venous access, so that this route may be considered as safe and effective as other approaches to central venous catheterization.
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Affiliation(s)
| | - Stefano Elli
- ASST Monza, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Bruno Marche
- Vascular Access Team, Fondazione Policlinico Universitario "A Gemelli," Roma, Italy
| | - Fulvio Pinelli
- Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Mauro Pittiruti
- Vascular Access Team, Fondazione Policlinico Universitario "A Gemelli," Roma, Italy
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14
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Brescia F, Annetta MG, Pinelli F, Pittiruti M. A GAVeCeLT bundle for PICC-port insertion: The SIP-Port protocol. J Vasc Access 2023:11297298231209521. [PMID: 37953715 DOI: 10.1177/11297298231209521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
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.
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Affiliation(s)
- Fabrizio Brescia
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Maria Giuseppina Annetta
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Fulvio Pinelli
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Firenze, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
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Pittiruti M, Celentano D, Barone G, D'Andrea V, Annetta MG, Conti G. A GAVeCeLT bundle for central venous catheterization in neonates and children: A prospective clinical study on 729 cases. J Vasc Access 2023; 24:1477-1488. [PMID: 35533085 DOI: 10.1177/11297298221074472] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In the pediatric patient, central venous catheterization may be associated with relevant complications. Though, most of them may be prevented by a wise choice of materials, methods, and techniques. Evidence-based insertion bundles for central venous catheterization have been developed in the adult patient, but not in neonates and children. METHODS The Italian Group for Long Term Venous Access Devices (GAVeCeLT) has developed an insertion bundle for central venous catheterization in neonates, infants, and children, which includes seven evidence-based strategies: (1) preprocedural ultrasound evaluation, (2) appropriate aseptic technique, (3) ultrasound guided venipuncture, (4) intraprocedural tip location by non-radiological methods, (5) proper choice of the exit site by tunneling, (6) sutureless securement, and (7) protection of the exit site using glue and transparent membranes. The effectiveness and safety of this bundle has been tested in a prospective study. RESULTS All neonates, infants and children requiring a non-emergency central line (except for umbilical venous catheters and epicutaneo-cava catheters) were included in the study. Out of 729 central line insertions, there were no immediate complications (no pneumothorax, no arterial puncture, no malposition); the incidence of early and late complications (local ecchymosis, dislodgment, local pain, exit site infection) was 3.7%; in the first 2 weeks after insertion, no catheter-related bacterial infection or catheter-related thrombosis was recorded. CONCLUSION The results of this prospective study strongly validate the hypothesis that an insertion bundle is highly effective in optimizing the safety of the maneuver, reducing immediate, early, and late complications.
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Affiliation(s)
- Mauro Pittiruti
- Department of Surgery, University Hospital "A. Gemelli," Rome, Italy
| | - Davide Celentano
- Pediatric Intensive Care Unit, University Hospital "A. Gemelli," Rome, Italy
| | - Giovanni Barone
- Neonatal Intensive Care Unit, "Infermi" Hospital, Rimini, Italy
| | - Vito D'Andrea
- Neonatal Intensive Care Unit, University Hospital "A. Gemelli," Rome, Italy
| | | | - Giorgio Conti
- Pediatric Intensive Care Unit, University Hospital "A. Gemelli," Rome, Italy
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16
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D'Andrea V, Prontera G, Pinna G, Cota F, Fattore S, Costa S, Migliorato M, Barone G, Pittiruti M, Vento G. Securement of Umbilical Venous Catheter Using Cyanoacrylate Glue: A Randomized Controlled Trial. J Pediatr 2023; 260:113517. [PMID: 37244573 DOI: 10.1016/j.jpeds.2023.113517] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/24/2023] [Accepted: 05/21/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To evaluate the role of cyanoacrylate glue in reducing dislodgement of umbilical venous catheters (UVCs). STUDY DESIGN This was a single-center, randomized, controlled, nonblinded trial. All infants requiring an UVC according to our local policy were included in the study. Infants with a UVC with a centrally located tip as verified by real-time ultrasound examination were eligible for the study. Primary outcome was the safety and efficacy of securement by cyanoacrylate glue plus cord-anchored suture (SG group) vs securement by suture alone (S group), as measured by reduction in dislodgment of the external tract of the catheter. Secondary outcomes were tip migration, catheter-related bloodstream infection, and catheter-related thrombosis. RESULTS In the first 48 hours after UVC insertion, dislodgement was significantly higher in the S group than in the SG group (23.1% vs 1.5%; P < .001). The overall dislodgement rate was 24.6% in the S group vs 7.7% in the SG group (P = .016). No differences were found in catheter-related bloodstream infection and catheter-related thrombosis. The incidence of tip migration was similar in both groups (S group 12.2% vs SG group 11.7%). CONCLUSIONS In our single-center study, cyanoacrylate glue was safe and effective for securement of UVCs, and particularly effective in decreasing early catheter dislodgments. TRIAL REGISTRATION UMIN-CTR Clinical Trial; Registration number: R000045844.
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Affiliation(s)
- Vito D'Andrea
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy.
| | - Giorgia Prontera
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Giovanni Pinna
- Neonatal Intensive Care Unit, Maternal-Fetal Department, "S. Camillo-Forlanini" Hospital, Rome, Italy
| | - Francesco Cota
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Simona Fattore
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Simonetta Costa
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Martina Migliorato
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Giovanni Barone
- Neonatal Intensive Care Unit, Infermi Hospital, Rimini, AUSL Romagna, Rimini, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Gemelli, Rome, Italy
| | - Giovanni Vento
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
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D'Andrea V, Pezza L, Prontera G, Ancora G, Pittiruti M, Vento G, Barone G. The intracavitary ECG method for tip location of ultrasound-guided centrally inserted central catheter in neonates. J Vasc Access 2023; 24:1134-1139. [PMID: 35081816 DOI: 10.1177/11297298211068302] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The correct position of the tip of a central venous access device is important in all patients, and especially in neonates. The traditional method of tip location (approximated intra-procedural length estimation + post procedural chest X-ray) is currently considered inaccurate and not cost-effective by most recent guidelines, which recommend the adoption of tip location by intracavitary electrocardiography (IC-ECG) whenever possible. METHODS This study prospectively investigated the applicability, the feasibility, the accuracy, and the safety IC-ECG for tip location in neonates requiring insertion of ultrasound-guided centrally inserted central venous catheters (CICCs) with caliber 3Fr or more. All catheter tip locations were verified using simultaneously both IC-ECG and ultrasound-based tip location, using the Neo-ECHOTIP protocol. RESULTS A total of 105 neonates were enrolled. The applicability of IC-ECG was 100% since a P wave was evident on the surface ECG of all neonates recruited for the study. The feasibility was also 100% since an increase of the P-wave was detected in all cases. The accuracy was also 100%, since a perfect match between IC-ECG based tip location and ultrasound-based tip location was found. There were no adverse events directly or indirectly related to the IC-ECG technique; no arrhythmias occurred. CONCLUSIONS When applied to ultrasound guided CICCs, tip location by IC-ECG is applicable and feasible in neonates, and it is safe and accurate.
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Affiliation(s)
- Vito D'Andrea
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Lucilla Pezza
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giorgia Prontera
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gina Ancora
- Neonatal Intensive Care Unit, Azienda Sanitaria Romagna, Infermi Hospital Rimini, Rimini, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Giovanni Vento
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Barone
- Neonatal Intensive Care Unit, Azienda Sanitaria Romagna, Infermi Hospital Rimini, Rimini, Italy
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Barone G, D'Andrea V, Ancora G, Cresi F, Maggio L, Capasso A, Mastroianni R, Pozzi N, Rodriguez-Perez C, Romitti MG, Tota F, Spagnuolo F, Raimondi F, Pittiruti M. The neonatal DAV-expert algorithm: a GAVeCeLT/GAVePed consensus for the choice of the most appropriate venous access in newborns. Eur J Pediatr 2023; 182:3385-3395. [PMID: 37195350 DOI: 10.1007/s00431-023-04984-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 05/18/2023]
Abstract
In most NICUs, the choice of the venous access device currently relies upon the operator's experience and preferences. However, considering the high failure rate of vascular devices in the neonatal population, such clinical choice has a critical relevance and should preferably be based on the best available evidence. Though some algorithms have been published over the last 5 years, none of them seems in line with the current scientific evidence. Thus, the GAVePed-which is the pediatric interest group of the most important Italian group on venous access, GAVeCeLT-has developed a national consensus about the choice of the venous access device in the neonatal population. After a systematic review of the available evidence, the panel of the consensus (which included Italian neonatologists specifically experts in this area) has provided structured recommendations answering four sets of questions regarding (1) umbilical venous catheters, (2) peripheral cannulas, (3) epicutaneo-cava catheters, and (4) ultrasound-guided centrally and femorally inserted central catheters. Only statements reaching a complete agreement were included in the final recommendations. All recommendations were also structured as a simple visual algorithm, so as to be easily translated into clinical practice. Conclusion: The goal of the present consensus is to offer a systematic set of recommendations on the choice of the most appropriate vascular access device in Neonatal Intensive Care Unit.
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Affiliation(s)
- Giovanni Barone
- Neonatal Intensive Care Unit, Infermi Hospital, AUSL Della Romagna, Viale Settembrini 2, Rimini, Italy.
| | - Vito D'Andrea
- Neonatal Intensive Care Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gina Ancora
- Neonatal Intensive Care Unit, Infermi Hospital, AUSL Della Romagna, Viale Settembrini 2, Rimini, Italy
| | - Francesco Cresi
- Neonatology and Neonatal Intensive Care Unit, Sant'Anna Hospital, University of Turin, Città Della Salute E Della Scienza, Turin, Italy
| | - Luca Maggio
- Neonatology and Neonatal Intensive Care Unit, AO San Camillo Forlanini, Rome, Italy
| | - Antonella Capasso
- Neonatology and Neonatal Intensive Care Unit, A.O.U. Federico 2, Naples, Italy
| | | | - Nicola Pozzi
- Neonatal Intensive Care Unit, San Pio Hospital, Benevento, Italy
| | - Carmen Rodriguez-Perez
- Neonatology and Neonatal Intensive Care Unit, ASST Spedali Civili, Ospedale Dei Bambini, Brescia, Italy
| | | | - Francesca Tota
- Neonatal Intensive Care Unit, Ospedale S. Chiara, APSS, Trento, Italy
| | - Ferdinando Spagnuolo
- Neonatal Intensive Care Unit, AOU Università Degli Studi Della Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Raimondi
- Neonatology and Neonatal Intensive Care Unit, A.O.U. Federico 2, Naples, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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D'Andrea V, Prontera G, Carlino R, Di Trani H, Carlettini I, Pittiruti M, Vento G. Optical detection of infiltration during peripheral intravenous infusion in neonates. J Vasc Access 2023:11297298231177723. [PMID: 37439226 DOI: 10.1177/11297298231177723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Infiltration and extravasation are common complications during peripheral intravenous infusion in the neonatal intensive care unit, and diagnosis is usually clinical, by inspection and palpation. Delay in diagnosis due to poor surveillance or misinterpretation of clinical signs may carry serious damage to the tissues of the neonate. Recently, a novel technology based on optical detection of infiltration has become available. METHODS We have studied two groups of term and preterm infants receiving non-vesicant intravenous infusions by the peripheral route (24G short peripheral cannulas), and we evaluated the incidence of infiltration. In the first group, we have compared the clinical detection of infiltration versus the detection obtained by a novel optical device, blinding the alarms of the device. In the second group, the comparison was carried out without blinding the alarms. RESULTS Of the neonates included in this study, 60% were female, 86% had a gestational age <37 weeks (34 ± 2.5 weeks) and a mean birth weight of 2.08 ± 0.4 g. Total recorded monitoring time was 1318 h and average monitoring time for each short peripheral cannula was 26.4 h. The incidence of infiltration was 80%, most of them having a Millam score <2. The novel device showed an overall sensitivity of 88.9% in detecting infiltration. Specificity was 84.4%, as evaluated assuming as standard the clinical diagnosis. Interestingly, in cases of documented infiltration, the event was diagnosed by the optical device approximately 6 h before the clinical diagnosis. CONCLUSIONS Continuous monitoring of the insertion site, as automatically ensured by this novel optical device, may play a complementary role in early detection of infiltration, even if the percentage of false positives and false negatives suggests that periodic clinical assessment by expert nurses cannot be omitted.
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Affiliation(s)
- Vito D'Andrea
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giorgia Prontera
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Riccardo Carlino
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Helena Di Trani
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Ilaria Carlettini
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Gemelli, Rome, Italy
| | - Giovanni Vento
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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20
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D'Arrigo S, Perna F, Annetta MG, Pittiruti M. Ultrasound-guided access to the axillary vein for implantation of cardiac implantable electronic devices: A systematic review and meta-analysis. J Vasc Access 2023; 24:854-863. [PMID: 34724839 DOI: 10.1177/11297298211054621] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The aims of our systematic review were to quantify the expected rate of procedural success, early and late complications during CIED implantation using US-guided puncture of the axillary vein and to perform a meta-analysis of those studies that compared the US technique (intervention) versus conventional techniques (control) in terms of complication rates. MEDLINE, ISI Web of Science, and EMBASE were searched for eligible studies. Pooled Odds Ratio (OR) and Pooled Mean Difference (PMD) for each predictor were calculated. The quality of evidence (QOE) was evaluated according to the GRADE guidelines. Thirteen studies were included a total of 2073 patients. The overall success of US-guided venipuncture for CIED implantation was 96.8%. As regards early complications, pneumothorax occurred in 0.19%, arterial puncture in 0.63%, and severe hematoma/bleeding requiring intervention in 1.1%. No cases of hemothorax, brachial plexus, or phrenic nerve injury were reported. As regards late complications, the incidence of pocket infection, venous thromboembolism, and leads dislodgement was respectively 0.4%, 0.8%, and 1.2%. In the meta-analysis (five studies), the intervention group (US-guided venipuncture) had a trend versus a lower likelihood of having a pneumothorax (0.19% vs 0.75%, p = 0.21), pocket hematoma (0.8% vs 1.7%, p = 0.32), infection (0.28% vs 1.05%, p = 0.29) than the control group, but this did not reach statistical significance. The overall QOE was low or very low. In conclusions we found that the US-guided axillary venipuncture for CIEDs implantation was associated with a low incidence of early and late complications and a steep learning curve.
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Affiliation(s)
- Sonia D'Arrigo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Perna
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Giuseppina Annetta
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Brescia F, Pittiruti M, Ostroff M, Spencer TR, Dawson RB. The SIF protocol: A seven-step strategy to minimize complications potentially related to the insertion of femorally inserted central catheters. J Vasc Access 2023; 24:527-534. [PMID: 34459295 DOI: 10.1177/11297298211041442] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The insertion of central venous catheters through the femoral veins is not uncommon and is potentially associated with the risk of immediate puncture-related complications and severe late complications as infection and thrombosis. As for other central venous access devices, the use of a standardized protocol of insertion and the correct application of evidence-based strategies are beneficial in reducing the risk of complications. We proposed a standardized protocol (S.I.F.: Safe Insertion of Femorally Inserted Central Catheters) consisting of seven strategies that should be part of vascular cannulation and should be adopted during the insertion of femoral venous catheters, aiming to minimize immediate, early and late insertion-related complications. These strategies include: preprocedural evaluation of the patient history and of the veins, appropriate aseptic technique, ultrasound guided puncture and cannulation of the vein, intra-procedural assessment of the tip position, adequate protection of the exit site, proper securement of the catheter, and appropriate coverage of the exit site.
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Affiliation(s)
- Fabrizio Brescia
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | | | - Robert B Dawson
- DNP, MSA, APRN, ACNP-BC, VA-BC Hospital Medicine and Vascular Access, Catholic Medical Center-Upper Connecticut Valley Hospital, Colebrook, NH, USA
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22
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Pinelli F, Little A, Kokotis K, Alsbrooks K, Pittiruti M. Assessment of the MAGIC recommendations in context of evolving evidence based on the use of PICC in ICU. J Vasc Access 2023; 24:836-847. [PMID: 34689644 DOI: 10.1177/11297298211048019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The goal of the 2015 Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) was to define indications and appropriate practices for peripherally inserted central catheters (PICC) use; however, MAGIC recommendations virtually reduced the use of PICC in hospital settings, including critical care. The aim of this review is to present an assessment of the MAGIC guidelines, considering contemporary evidence to date. The validity of the MAGIC recommendations and their applicability to current practice are called into question given important concerns with the methodology for their development (e.g. high volume of clinical scenarios for evaluation) and the supporting evidence used. There is a considerable amount of contemporary evidence not considered in MAGIC that reports on evolving practices, techniques, and technologies targeted to reduce complications associated with central venous access devices (CVADs). Recent evidence dictates that CVADs are necessary in the intensive care unit (ICU), and that PICCs are a safe, reliable, and appropriate type of central lines, which cannot be replaced in several ICU situations. In light of evolving evidence and practice, as well as the methodological concerns identified, the MAGIC guidelines should be revisited. It is also recommended to create a clinical assessment tool that identifies potential uses of specific CVADs, based on patient needs. The choice of the CVAD should be based on unique clinical considerations and current scientific evidence, not on fears informed by antiquated data.
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Affiliation(s)
- Fulvio Pinelli
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | | | - Kathy Kokotis
- Becton Dickinson and Company, Franklin Lakes, NJ, USA
| | - Kim Alsbrooks
- Becton Dickinson and Company, Franklin Lakes, NJ, USA
| | - Mauro Pittiruti
- Department of Surgery, Catholic University Hospital, Rome, Italy
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23
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Marche B, D'Arrigo S, Annetta MG, Musarò A, Emoli A, Sica S, Piccirillo N, Putzulu R, De Paolis M, Bernoldi M, Pittiruti M. Midline catheters for extracorporeal photopheresis in hematological patients. J Vasc Access 2023; 24:568-574. [PMID: 34459312 DOI: 10.1177/11297298211041450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Peripheral venous access for extracorporeal photopheresis (ECP) may be difficult in graft versus host disease (GVHD) patients, because of previous intravenous therapies and multiple peripheral cannulations; in this population of patients, ultrasound guided midline catheters may be an alternative option to central venous access. METHODS In this single-center, prospective preliminary study, we enrolled all consecutive patients with a diagnosis of GVHD and candidate to ECP, over a period of 10 months. We used inserted power injectable, non-valved, polyurethane, 20-25 cm single lumen midline catheters (MC). RESULTS Sixty-nine ECP procedures were carried out in six patients, using single-lumen MCs for outflow (5Fr in 74% and 4Fr in 26% of cases). For inflow, we used 5Fr or 4Fr MCs, or central venous access devices previously placed for other clinical reasons. There were no catheter-related complications during the entire period of ECP treatment. Mean outflow was significantly higher for 5Fr than for 4Fr MCs (35.8 ± 7.3 vs 29.2 ± 7.8 ml/min; p = 0.0008) and the procedure time was significantly shorter (92.9 ± 9.2 vs 108 ± 13.2 min; p < 0.0001). CONCLUSION In GVHD patients, ECP can be performed efficiently and safely using single lumen polyurethane power injectable MCs. The best results are obtained with 5Fr rather than with 4Fr catheters. This strategy of venous access should be implemented in DIVA patients requiring ECP treatments, and probably also in other types of apheresis.
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Affiliation(s)
- Bruno Marche
- Department of Hematology, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sonia D'Arrigo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Giuseppina Annetta
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Musarò
- Department of Oncologic Gynecology, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Emoli
- Department of Oncology, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simona Sica
- Department of Hematology, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicola Piccirillo
- Transfusion Medicine Department, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rossana Putzulu
- Transfusion Medicine Department, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria De Paolis
- Transfusion Medicine Department, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Bernoldi
- Transfusion Medicine Department, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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24
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Greca AL, Iacobone E, Elisei D, Biasucci DG, D'Andrea V, Barone G, Zito Marinosci G, Pittiruti M. ECHOTIP: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in adult patients. J Vasc Access 2023; 24:535-544. [PMID: 34494474 DOI: 10.1177/11297298211044325] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Central venous access devices are routinely used in clinical practice for administration of fluids and medications, for drawing blood samples and for hemodynamic monitoring. The adoption of ultrasound guided venipuncture has significantly reduced procedure-related complications, as documented by the recommendations of most recent guidelines. Ultrasound has also an important role also in other aspects of central venous catheterization, such as in the pre-procedural evaluation of the venous patrimony and in the detection of early and late non-infective complications. Recently, bedside ultrasound has been regarded as a promising tool also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in adult patients, and to suggest a structured standardized protocol for clinical practice.
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Affiliation(s)
- Antonio La Greca
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Emanuele Iacobone
- Department of Intensive Care and Anesthesia, Central Hospital, Macerata, Italy
| | - Daniele Elisei
- Department of Intensive Care and Anesthesia, Central Hospital, Macerata, Italy
| | - Daniele Guerino Biasucci
- Department of Emergency, Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Vito D'Andrea
- Neonatal Intensive Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Barone
- Neonatal Intensive Care Unit, Ospedale Infermi di Rimini, Azienda Unità Sanitaria Locale della Romagna, Rimini, Italy
| | - Geremia Zito Marinosci
- UOC di Rianimazione e Neuroanestesia, Azienda Ospedaliera Santobono-Pausilipon, Naples, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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25
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Spencer TR, Imbriaco G, Bardin-Spencer A, Mahoney KJ, Brescia F, Lamperti M, Pittiruti M. Safe Insertion of Arterial Catheters (SIA): An ultrasound-guided protocol to minimize complications for arterial cannulation. J Vasc Access 2023:11297298231178064. [PMID: 37265235 DOI: 10.1177/11297298231178064] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
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.
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26
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Annetta MG, Marche B, Mercurio G, Pittiruti M. Ultrasound based tip location of femorally inserted central catheters into the inferior vena cava: A comparison between the transhepatic and the subcostal view. J Vasc Access 2023:11297298231178063. [PMID: 37249165 DOI: 10.1177/11297298231178063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Intraprocedural catheter tip location is currently recommended. Intracavitary EGC and ultrasound are the preferred methods of tip location for catheters with their tip in the superior vena cava or in the right atrium. Though, the best method of intraprocedural tip location for catheters with their tip in the inferior vena cava is still uncertain. One possibility is to visualize the subdiaphragmatic inferior vena cava by ultrasound, using either the transhepatic or the subxiphoid view. METHODS In this prospective study, we compared two different ultrasound windows for the visualization of the inferior vena cava (transhepatic vs subxiphoid) for the purpose of localizing the catheter tip during the insertion of femorally inserted central catheters. RESULTS We studied 249 consecutive insertions of central catheters via the superficial femoral vein. Intraprocedural location of the catheter tip was performed by ultrasound, using both transhepatic and subxiphoid view. Visualization of the inferior vena cava was possible only in 81 cases (32.5%) with the subxiphoid view, but it was always possible in all 249 cases with the transhepatic view. The catheter tip was localized in 15 patients out of 81 with the subxiphoid view (18.5%); the transhepatic view allowed the visualization of the tip in all 249 patients. CONCLUSIONS The applicability of the subxiphoid window has several limitations, both in terms of visualization of the inferior vena cava and localization of the catheter tip. The transhepatic view should be the preferred method for intraprocedural ultrasound localization of the catheter tip in the inferior vena cava.
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Affiliation(s)
- Maria Giuseppina Annetta
- Department of Anesthesia and Intensive Care, Catholic University Hospital "A.Gemelli," Rome, Lazio, Italy
| | - Bruno Marche
- Department of Hematology, Catholic University Hospital "A.Gemelli," Rome, Lazio, Italy
| | - Giovanna Mercurio
- Department of Anesthesia and Intensive Care, Catholic University Hospital "A.Gemelli," Rome, Lazio, Italy
| | - Mauro Pittiruti
- Department of Surgery, Catholic University Hospital "A.Gemelli," Rome, Lazio, Italy
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27
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Frondizi F, Dolcetti L, Pittiruti M, Calabrese M, Fantoni M, Biasucci DG, Scoppettuolo G. Complications associated with the use of peripherally inserted central catheters and midline catheters in COVID-19 patients: An observational prospective study. Am J Infect Control 2023:S0196-6553(23)00357-7. [PMID: 37160191 PMCID: PMC10164288 DOI: 10.1016/j.ajic.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/29/2023] [Accepted: 05/01/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Among the many interesting aspects of clinical care during the SARS-CoV-2 pandemic, vascular access still deserves some attention. Peripherally inserted central catheters (PICCs) and midline catheters (MCs) are venous access devices inserted by ultrasound-guided puncture of veins of the arm, which have been associated with the possibility of minimizing infectious complications in different populations of patients. We have investigated their performance in SARS-CoV-2 patients. METHODS As the incidence of catheter-related bloodstream infections (CRBSI) in patients hospitalized for COVID-19 is still unclear, we have designed a single-center, prospective observational study enrolling all patients with established diagnosis of SARS-CoV-2 infection who were admitted to our hospital in the period between October 2020 and April 2021 and who required either a PICC or a MC. RESULTS We recruited 227 patients. The cumulative incidence of CRBSI was 4.35% (10 cases), that is, 3.5 episodes/1,000 catheter days. Four CRBSI occurred in patients with PICCs (4.5/1,000 catheter days) and 6 in those with MCs (3.2/1,000 catheter days). CONCLUSIONS Our data suggest that COVID-19 patients may have a more pronounced tendency for the development of catheter-related infections compared to other populations of patients.
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Affiliation(s)
- Federico Frondizi
- Dipartimento di Sicurezza e Bioetica, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Laura Dolcetti
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mauro Pittiruti
- Dipartimento di Scienze della Salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Calabrese
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Massimo Fantoni
- Dipartimento di Sicurezza e Bioetica, Università Cattolica del Sacro Cuore, Rome, Italy; Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Daniele Guerino Biasucci
- Dipartimento di Scienze Cliniche e Medicina Translazionale, Università degli Studi di Roma Tor Vergata, Rome, Italy
| | - Giancarlo Scoppettuolo
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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28
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Ostroff MD, Moureau N, Pittiruti M. Rapid Assessment of Vascular Exit Site and Tunneling Options (RAVESTO): A new decision tool in the management of the complex vascular access patients. J Vasc Access 2023; 24:311-317. [PMID: 34289721 DOI: 10.1177/11297298211034306] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In the last decade, different standardized protocols have been developed for a systematic ultrasound venous assessment before central venous catheterization: RaCeVA (Rapid Central Vein Assessment), RaPeVA (Rapid Peripheral Vein Assessment), and RaFeVA (Rapid Femoral Vein Assessment). Such protocols were designed to locate the ideal puncture site to minimize insertion-related complications. Recently, subcutaneous tunneling of non-cuffed central venous access devices at bedside has also grown in acceptance. The main rationale for tunneling is to relocate the exit site based on patient factors and concerns for dislodgement. The tool we describe (RAVESTO-Rapid Assessment of Vascular Exit Site and Tunneling Options) defines the different options of subcutaneous tunneling and their indications in different clinical situations in patients with complex vascular access.
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Affiliation(s)
| | - Nancy Moureau
- PICC Excellence, Inc., Infinity Infusion Nursing, Griffith University, Hartwell, GA, USA
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29
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Brescia F, Pittiruti M, Ostroff M, Spencer TR, Dawson RB. The SIC protocol: A seven-step strategy to minimize complications potentially related to the insertion of centrally inserted central catheters. J Vasc Access 2023; 24:185-190. [PMID: 34320856 DOI: 10.1177/11297298211036002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Insertion of central venous catheters in the cervico-thoracic area is potentially associated with the risk of immediate/early untoward events, some of them negligible (repeated punctures), some relevant (accidental arterial puncture), and some severe (pneumothorax). Furthermore, different strategies adopted during insertion may reduce or increase the incidence of late catheter-related complications (infection, venous thrombosis, dislodgment). This paper describes a standardized protocol (S.I.C.: Safe Insertion of Centrally Inserted Central Catheters) for the systematic application of seven basic beneficial strategies to be adopted during insertion of central venous catheters in the cervico-thoracic region, aiming to minimize immediate, early, or late insertion-related complications. These strategies include: preprocedural evaluation, appropriate aseptic technique, ultrasound guided insertion, intra-procedural assessment of the tip position, adequate protection of the exit site, proper securement of the catheter, and adequate coverage of the exit site.
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Affiliation(s)
- Fabrizio Brescia
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | | | | | - Robert B Dawson
- Catholic Medical Center - Upper Connecticut Valley Hospital, Colebrook, NH, USA
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30
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Putzulu R, Romano A, Mancino A, Corbingi A, Massini G, Mastrangelo S, Pulitanò SM, Piastra M, Pittiruti M, Ruggiero A, Piccirillo N. Successful stem cell collection for atypical teratoid rhabdoid tumor in an extremely low-body weight child: A case report. J Clin Apher 2023. [PMID: 36861176 DOI: 10.1002/jca.22044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/13/2023] [Accepted: 02/14/2023] [Indexed: 03/03/2023]
Abstract
The use of peripheral blood hematopoietic stem cells for bone marrow reconstitution after myeloablative therapy is well established in children with malignant disorders. However, the peripheral blood hematopoietic stem cells collection in very low-body weight (≤10 kg) children remains a significant challenge because of technical and clinical issues. A male newborn affected by atypical teratoid rhabdoid tumor, diagnosed prenatally, received two cycles of chemotherapy following surgical resection. After an interdisciplinary discussion, it was decided to intensify the treatment with high-dose chemotherapy followed by autologous stem cell transplantation. After 7 days of G-CSF administration the patient underwent hematopoietic progenitor cells-apheresis collection. The procedure was performed in the pediatric intensive care unit, using two central venous catheters and Spectra Optia device. The cell collection procedure was completed in 200 min, during which time 3.9 total blood volumes were processed. During apheresis we did not observe electrolyte alterations. No adverse events were recorded during or immediately following the cell collection procedure. Our report describes the feasibility of performing large volume leukapheresis without complications in an extremely low-body weight patient weighing 4.5 kg using the Spectra Optia apheresis device. No catheter-related problems occurred, and apheresis was completed without any adverse event. In conclusion, we believe that very low-body weight pediatric patients need a multidisciplinary approach to manage central venous access, hemodynamic monitoring, cell collection, prevention of metabolic complications to improve safety, feasibility, and efficiency of stem cell collection procedures.
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Affiliation(s)
- Rossana Putzulu
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico A. Gemelli IRCCS, Largo A. Gemelli, Rome, Italy
| | - Alberto Romano
- UOSD di Oncologia Pediatrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Largo A. Gemelli, Rome, Italy
| | - Aldo Mancino
- Pediatric Intensive Care Unit and Pediatric Trauma Centre, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Largo A. Gemelli, Rome, Italy
| | - Andrea Corbingi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico A. Gemelli IRCCS, Largo A. Gemelli, Rome, Italy
| | - Giuseppina Massini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico A. Gemelli IRCCS, Largo A. Gemelli, Rome, Italy
| | - Stefano Mastrangelo
- UOSD di Oncologia Pediatrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Largo A. Gemelli, Rome, Italy.,Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Largo A. Gemelli, Rome, Italy
| | - Silvia Maria Pulitanò
- Pediatric Intensive Care Unit and Pediatric Trauma Centre, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Largo A. Gemelli, Rome, Italy.,Pediatric Intensive Care Unit and Pediatric Trauma Centre, Catholic University of the Sacred Heart of Rome, Largo A. Gemelli, Rome, Italy
| | - Marco Piastra
- Pediatric Intensive Care Unit and Pediatric Trauma Centre, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Largo A. Gemelli, Rome, Italy.,Pediatric Intensive Care Unit and Pediatric Trauma Centre, Catholic University of the Sacred Heart of Rome, Largo A. Gemelli, Rome, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, Rome, Italy
| | - Antonio Ruggiero
- UOSD di Oncologia Pediatrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Largo A. Gemelli, Rome, Italy.,Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Largo A. Gemelli, Rome, Italy
| | - Nicola Piccirillo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico A. Gemelli IRCCS, Largo A. Gemelli, Rome, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Largo A. Gemelli, Rome, Italy
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31
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Zanaboni C, Bevilacqua M, Bernasconi F, Appierto L, Annetta MG, Pittiruti M. Caliber of the deep veins of the arm in infants and neonates: The VEEIN study (Vascular Echography Evaluation in Infants and Neonates). J Vasc Access 2023:11297298221150942. [PMID: 36655541 DOI: 10.1177/11297298221150942] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Ultrasound-guided peripherally inserted central catheters (PICCs) are increasingly used in children, though their insertion may be limited by the small caliber of the deep veins of the arm. Previous studies have suggested to use age or weight as a guide to the feasibility of PICC insertion. We have planned an observational study with the purpose of identifying the actual feasibility of PICC insertion based on the ultrasound evaluation of the deep veins of the arm in groups of children of different weight range. METHODS We have studied 252 children weighing between 2.5 and 20 kg, divided in five different groups (group 1: 2.5-4 kg; group 2: 4.1-7 kg; group 3: 7.1-10 kg; group 4: 10.1-15 kg; group 5: 15.1-20 kg): the caliber of brachial vein, basilic vein, and cephalic vein at mid-upper arm + the caliber of the axillary vein at the axilla were measured by ultrasound scan. RESULTS Veins of caliber >3 mm (appropriate for insertion of a 3 Fr non-tunneled PICC) were found at mid-upper arm in no child of group 1 or 2, in 13% of group 3, in 28% of group 4, and in 54% of group 5. An axillary vein >3 mm (appropriate for insertion of a 3 Fr tunneled PICC) were found in 5.8% of group 1, 30.6% of group 2, 67% of group 3, 82% of group 4, and 94% of group 5. CONCLUSIONS The age and the weight of the child have a small role in predicting the caliber of the veins of the arm. Veins should be measured case by case through a proper and systematic ultrasound evaluation; however, the clinician can expect that insertion of a 3 Fr PICC may be feasible in one third of children weighing between 4 and 7 kg, and in most children weighing more than 7 kg, especially if adopting the tunneling technique.
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Affiliation(s)
- Clelia Zanaboni
- Department of Pediatric Anesthesia and Intensive Care, General Hospital, Parma, Italy
| | - Michela Bevilacqua
- Pediatric Intensive Care Unit, Pediatric Hospital "G.Gaslini," Genova, Italy
| | - Filippo Bernasconi
- Neurological Intensive Care Unit, General Hospital "Niguarda," Milano, Italy
| | - Linda Appierto
- Department of Anesthesia, Pediatric Hospital "Bambino Gesù," Roma, Italy
| | | | - Mauro Pittiruti
- Department of Surgery, University Hospital "Gemelli," Roma, Italy
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32
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Pittiruti M, Van Boxtel T, Scoppettuolo G, Carr P, Konstantinou E, Ortiz Miluy G, Lamperti M, Goossens GA, Simcock L, Dupont C, Inwood S, Bertoglio S, Nicholson J, Pinelli F, Pepe G. European recommendations on the proper indication and use of peripheral venous access devices (the ERPIUP consensus): A WoCoVA project. J Vasc Access 2023; 24:165-182. [PMID: 34088239 DOI: 10.1177/11297298211023274] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Since several innovations have recently changed the criteria of choice and management of peripheral venous access (new devices, new techniques of insertion, new recommendations for maintenance), the WoCoVA Foundation (WoCoVA = World Conference on Vascular Access) has developed an international Consensus with the following objectives: to propose a clear and useful classification of the currently available peripheral venous access devices; to clarify the proper indication of central versus peripheral venous access; discuss the indications of the different peripheral venous access devices (short peripheral cannulas vs long peripheral cannulas vs midline catheters); to define the proper techniques of insertion and maintenance that should be recommended today. To achieve these purposes, WoCoVA have decided to adopt a European point of view, considering some relevant differences of terminology between North America and Europe in this area of venous access and the need for a common basis of understanding among the experts recruited for this project. The ERPIUP Consensus (ERPIUP = European Recommendations for Proper Indication and Use of Peripheral venous access) was designed to offer systematic recommendations for clinical practice, covering every aspect of management of peripheral venous access devices in the adult patient: indication, insertion, maintenance, prevention and treatment of complications, removal. Also, our purpose was to improve the standardization of the terminology, bringing clarity of definition, and classification.
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Affiliation(s)
| | | | | | - Peter Carr
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | | | | | | | - Godelieve Alice Goossens
- Nursing Centre of Excellence, University Hospitals, Leuven, Belgium and Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Belgium
| | - Liz Simcock
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Christian Dupont
- Cochin University Hospital, Assistance Publique - Hôpitaux de Paris, France
| | | | | | - Jackie Nicholson
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Gilda Pepe
- Catholic University Hospital 'A. Gemelli', Rome, Italy
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Crocoli A, Martucci C, Sidro L, Delle Donne D, Menna G, Pittiruti M, De Pasquale MD, Strocchio L, Natali GL, Inserra A. Safety and effectiveness of subcutaneously anchored securement for tunneled central catheters in oncological pediatric patients: A retrospective study. J Vasc Access 2023; 24:35-40. [PMID: 34088245 DOI: 10.1177/11297298211009364] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Proper securement of central venous catheters plays an important role in onco-hematological pediatric patients. A new subcutaneously anchored securement device has been recently introduced in the clinical practice, and it has been extensively used in children. METHOD In our study, we have retrospectively investigated the safety and the effectiveness of such device, reviewing the experience of three Italian pediatric oncological units. We have considered only tunneled catheters (cuffed or non-cuffed) inserted in children with malignancy; all types of tunneled central catheters were included in the analysis (both centrally and peripherally inserted) as long as they were secured with a subcutaneously anchored device. We investigated the incidence of dislodgment and of other catheter-related complications, with special attention to local adverse effects potentially related to the securement device. RESULTS We collected data from 311 tunneled catheters of different caliber: 80.4% were centrally inserted central catheters (CICC), 15.4% were peripherally inserted (PICC), and 4.2% were femorally inserted. Approximately half of the catheters (51%) were non-cuffed. Incidence of dislodgment was very low (2.6%) and the incidence of local pain or inflammation potentially related to the securement device was minimal (1.9%). Catheter related bacteremias were below 1 episode/1000 catheter days. No symptomatic catheter related thrombosis was reported. There was no significant difference in complications comparing cuffed versus non-cuffed catheters, or CICCs versus PICCs, or hematologic tumors versus solid tumors. CONCLUSION In our retrospective analysis of a vast population of oncological pediatric patients with tunneled central catheters, the subcutaneously anchored securement device was tolerated very well, and it was highly effective in preventing dislodgment, both in cuffed and non-cuffed catheters.
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Affiliation(s)
- Alessandro Crocoli
- Surgical Oncology Unit, Bambino Gesù Children Hospital IRCCS, Rome, Italy
| | - Cristina Martucci
- Surgical Oncology Unit, Bambino Gesù Children Hospital IRCCS, Rome, Italy
| | - Luca Sidro
- Department of Anesthesiology and Intensive Care, Santobono-Pausilipon Children Hospital, Naples, Italy
| | - Daniela Delle Donne
- Department of Anesthesiology and Intensive Care, Santobono-Pausilipon Children Hospital, Naples, Italy
| | - Giuseppe Menna
- Department of Pediatric Hemato-Oncology, Santobono-Pausilipon Children Hospital, Naples, Italy
| | - Mauro Pittiruti
- Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | | | - Luisa Strocchio
- Department of Oncohematology, Bambino Gesù Children Hospital IRCCS, Rome, Italy
| | - Gian Luigi Natali
- Oncohematologic Interventional Radiology Unit, Imaging Department, Bambino Gesù Children Hospital IRCCS, Rome, Italy
| | - Alessandro Inserra
- Surgical Oncology Unit, Bambino Gesù Children Hospital IRCCS, Rome, Italy
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Annetta MG, Ostroff M, Marche B, Emoli A, Musarò A, Celentano D, Taraschi C, Dolcetti L, Greca AL, Scoppettuolo G, Pittiruti M. Chest-to-arm tunneling: A novel technique for medium/long term venous access devices. J Vasc Access 2023; 24:92-98. [PMID: 34148390 DOI: 10.1177/11297298211026825] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Chest-to-arm (CTA) tunneling has been described recently as a technique that allows an optimal exit site at mid-arm even in chronically ill patients with complex clinical issues and challenging problems of vascular access. METHOD We adopted CTA tunneling in oncologic and in non-oncologic patients, in totally implanted and in external devices, for both medium and long-term intravenous treatments. We report our experience with 60 cases of CTA tunneling: 19 patients requiring a totally implantable device, who had bilateral contraindication to venous access at the arm and bilateral contraindication to placement of the pocket in the infra-clavicular area; 41 patients requiring an external central venous catheter, who had bilateral contraindication to insertion of peripherally inserted central catheters or femoral catheters, as well as contraindication to an exit site in the infraclavicular area. All venous access devices were inserted with ultrasound guidance and tip location by intracavitary electrocardiography, under local anesthesia. RESULTS There were no immediate or early complications. Patients with CTA-ports had no late complications. In patients with CTA-tunneled external catheters, there were two dislodgments, four episodes of central line associated blood stream infections, and one local infection. There were no episodes of venous thrombosis or catheter malfunction. CONCLUSION Our experience suggests that CTA tunneling is a safe maneuver, with very low risk of complications, and should be considered as an option in patients with complex venous access.
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Affiliation(s)
| | - Matt Ostroff
- St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Bruno Marche
- Fondazione Policlinico Universitario "A.Gemelli", Rome, Italy
| | | | - Andrea Musarò
- Fondazione Policlinico Universitario "A.Gemelli", Rome, Italy
| | | | | | - Laura Dolcetti
- Fondazione Policlinico Universitario "A.Gemelli", Rome, Italy
| | | | | | - Mauro Pittiruti
- Fondazione Policlinico Universitario "A.Gemelli", Rome, Italy
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D'Arrigo S, Annetta MG, Pittiruti M. An ultrasound-based technique in the management of totally implantable venous access devices with persistent withdrawal occlusion. J Vasc Access 2023; 24:140-144. [PMID: 34096379 DOI: 10.1177/11297298211023275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Persistent withdrawal occlusion is a specific catheter malfunction characterized by inability to withdraw blood through the device while infusion is maintained. The main causes are fibroblastic sleeve and tip malposition (associated or not to venous thrombosis around the tip). All current guidelines recommend infusing vesicant/antiblastic drugs through a central venous port only after assessment of blood return. In PWO, blood return is impossible. We have recently started to assess the intravascular position of the tip and the delivery of the infusion in the proximity of the cavo-atrial junction utilizing transthoracic/subxiphoid ultrasound with the 'bubble test'. We found that this is an easy, real-time, accurate and safe method for verifying the possibility of using a port for chemotherapy even in the absence of blood return, as it occurs with persistent withdrawal occlusion.
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Affiliation(s)
- Sonia D'Arrigo
- Deptartment of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Giuseppina Annetta
- Deptartment of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mauro Pittiruti
- Deptartment of Surgery, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Brescia F, Pittiruti M, Roveredo L, Zanier C, Morabito A, Santarossa E, Da Ros V, Montico M, Fabiani F. Subcutaneously anchored securement for peripherally inserted central catheters: Immediate, early, and late complications. J Vasc Access 2023; 24:82-86. [PMID: 34137321 DOI: 10.1177/11297298211025430] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND An adequate stabilization of a vascular device is an important part of insertion bundles and is an effective strategy in reducing complications. Dislodgment has a relevant clinical impact and an increase in healthcare costs. METHOD We have retrospectively investigated the safety and efficacy of Subcutaneously Anchored Securement (SAS) for Peripherally Inserted Central Catheters (PICC) in cancer patients. RESULTS We analyzed 639 patients who had a PICC inserted and secured with SAS, over the past 3 years (2018-2020). No immediate complications during SAS placement were reported. In the first 24-48 h, a slight local ecchymosis was reported in 24 cases with rapid spontaneous resolution. No cases of bleeding or hematoma of the exit site were reported. The total number of catheter days was 93078. Dislodgment occurred only in seven cases (1.1%). In 16 patients, the PICC was removed because of catheter-related bloodstream infection (CRBSI): the overall incidence of CRBSI was 0.17 per 1000 catheter days. Symptomatic venous thrombosis was documented in 12 patients (1.9%) and treated with low molecular weight heparin without PICC removal. We had no cases of irreversible lumen occlusion. In 17 patients, local discomfort-including device-related pressure ulcers and painful inflammation-was reported: these cases were treated without SAS removal or PICC removal. CONCLUSION In this retrospective analysis, subcutaneously anchored securement of PICCs was a safe and effective strategy for reducing the risk of dislodgment.
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Affiliation(s)
- Fabrizio Brescia
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Laura Roveredo
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Chiara Zanier
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Antonietta Morabito
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Elisabetta Santarossa
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Valentina Da Ros
- Clinical Oncology Department, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Marcella Montico
- Clinical Trial Office, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Fabio Fabiani
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
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Brescia F, Pittiruti M, Scoppettuolo G, Zanier C, Nadalini E, Bottos P, Moreal C, Da Ros V, Fabiani F. Taurolidine lock in the treatment of colonization and infection of totally implanted venous access devices in cancer patients. J Vasc Access 2023; 24:87-91. [PMID: 34148394 DOI: 10.1177/11297298211026453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Taurolidine lock is known to be effective in preventing catheter-related infections in a variety of venous access devices, including long term venous access devices for chemotherapy. Though, literature about the use of taurolidine for treating catheter colonization or catheter-related blood stream infection is scarce. METHOD We have retrospectively reviewed the safety and efficacy of 2% taurolidine lock for treatment of catheter-colonization and of catheter-related bloodstream infection in cancer patients with totally implanted venous access devices. Diagnosis of colonization or catheter-related infection was based on paired peripheral and central blood cultures, according to the method of Delayed Time to Positivity. RESULTS We recorded 24 cases of catheter-related infection and two cases of colonization. Taurolidine lock-associated with systemic antibiotic therapy-was successful in treating all cases of catheter-related infection, with disappearance of clinical symptoms, normalization of laboratory values, and eventually negative blood cultures. Taurolidine lock was also safe and effective in treating device colonization. No adverse effect was reported. CONCLUSION In our retrospective analysis, 2% taurolidine lock was completely safe and highly effective in the treatment of both catheter-colonization and catheter-related bloodstream infection in cancer patients with totally implanted venous access devices.
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Affiliation(s)
- Fabrizio Brescia
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Giancarlo Scoppettuolo
- Department of Infectious Diseases, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Chiara Zanier
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Elisa Nadalini
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Paola Bottos
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Chiara Moreal
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Valentina Da Ros
- Clinical Oncology Department, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Fabio Fabiani
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
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Zito Marinosci G, Biasucci DG, Barone G, D'Andrea V, Elisei D, Iacobone E, La Greca A, Pittiruti M. ECHOTIP-Ped: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in pediatric patients. J Vasc Access 2023; 24:5-13. [PMID: 34256613 DOI: 10.1177/11297298211031391] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Central venous access devices are routinely used in pediatric care for administration of fluids and medications and for drawing blood samples. The adoption of ultrasound guided venipuncture, the availability of bedside ultrasound devices and the use of intraprocedural methods for tip location have been shown to reduce procedure-related complications, as documented by the recommendations of most recent guidelines. In pediatric patients, bedside ultrasound is a promising tool not only for optimizing the choice of the vein and guiding the venipuncture, but also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in pediatric patients, and to suggest a structured protocol for clinical practice.
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Affiliation(s)
- Geremia Zito Marinosci
- UOC di Rianimazione e Neuroanestesia, Azienda Ospedaliera di Rilievo Nazionale Santobono-Pausilipon, Neaples, Italy
| | - Daniele Guerino Biasucci
- Department of Emergency, Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Barone
- Neonatal Intensive Care Unit, Ospedale Infermi di Rimini, Azienda Unità Sanitaria Locale della Romagna, Rimini, Italy
| | - Vito D'Andrea
- Neonatal Intensive Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Daniele Elisei
- Department of Intensive Care and Anesthesia, Central Hospital, Macerata, Italy
| | - Emanuele Iacobone
- Department of Intensive Care and Anesthesia, Central Hospital, Macerata, Italy
| | - Antonio La Greca
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Pittiruti M, Salerno G, Mancino A, Carlini D, Celentano D, Annetta MG, Conti G. Ultrasound versus intracavitary electrocardiography for intraprocedural tip location during central venous catheterization in infants and children: A prospective clinical study. J Vasc Access 2022:11297298221132415. [PMID: 36267035 DOI: 10.1177/11297298221132415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Both intracavitary electrocardiography (IC-ECG) and ultrasound (US) have been proven to be safe and accurate for intraprocedural tip location during central venous catheterization, and both are known to be easily applicable and feasible in pediatric patients. Though, no prospective clinical study has directly compared the two methods as regards their applicability, feasibility, and procedural time. METHODS This study prospectively enrolled all children requiring a central venous access device in non-emergency situations, during a period of 1 year. All devices were inserted according to a well-defined insertion bundle including both IC-ECG and US-based tip location. The primary endpoint of the study was to compare the two methods in terms of applicability, feasibility and time required. RESULTS This study included 100 consecutive central venous catheterizations in children of age ranging from 1 month to 18 years. The applicability of IC-ECG based tip location was 98% and its feasibility 100%; the time required for IC-ECG was 1.9 ± 2 min. The applicability of US-based tip location was 96% and its feasibility was 100%; the maneuver required 2.2 ± 3 min. CONCLUSIONS US is an appropriate alternative method for intraprocedural tip location in children. The combined use of US and IC-ECG (both maneuvers being accurate, inexpensive, cost-effective, non-invasive, and equally fast to perform) should be recommended for tip location in pediatric patients, and it will avoid completely the use of fluoroscopy or of post-procedural x-ray.
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Affiliation(s)
- Mauro Pittiruti
- Department of Surgery, University Hospital 'Fondazione Policlinico A.Gemelli', Rome, Italy
| | - Gilda Salerno
- Pediatric Intensive Care Unit, University Hospital 'Fondazione Policlinico A.Gemelli', Rome, Italy
| | - Aldo Mancino
- Pediatric Intensive Care Unit, University Hospital 'Fondazione Policlinico A.Gemelli', Rome, Italy
| | - Debora Carlini
- Pediatric Intensive Care Unit, University Hospital 'Fondazione Policlinico A.Gemelli', Rome, Italy
| | - Davide Celentano
- Department of Oncology, University Hospital 'Fondazione Policlinico A.Gemelli', Rome, Italy
| | - Maria Giuseppina Annetta
- Department of Anesthesia and Intensive Care, University Hospital 'Fondazione Policlinico A.Gemelli', Rome, Italy
| | - Giorgio Conti
- Department of Anesthesia and Intensive Care, University Hospital 'Fondazione Policlinico A.Gemelli', Rome, Italy
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40
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Barone G, Pittiruti M, D'Andrea V. Ultrasound-guided catheter tip location in neonatal central venous access. Focus on well-defined protocols and proper ultrasound training. J Pediatr 2022; 247:181. [PMID: 35644226 DOI: 10.1016/j.jpeds.2022.05.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/18/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Giovanni Barone
- Neonatal Intensive Care Unit, Infermi Hospital, Rimini, AUSL Romagna, Rimini, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Gemelli, Rome, Italy
| | - Vito D'Andrea
- Neonatal Intensive Care Unit, Fondazione Policlinico Gemelli, Rome, Italy
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Annetta MG, Bertoglio S, Biffi R, Brescia F, Giarretta I, Greca AL, Panocchia N, Passaro G, Perna F, Pinelli F, Pittiruti M, Prisco D, Sanna T, Scoppettuolo G. Management of antithrombotic treatment and bleeding disorders in patients requiring venous access devices: A systematic review and a GAVeCeLT consensus statement. J Vasc Access 2022; 23:660-671. [PMID: 35533088 DOI: 10.1177/11297298211072407] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Insertion of venous access devices (VAD) is usually considered a procedure with low risk of bleeding. Nonetheless, insertion of some devices is invasive enough to be associated with bleeding, especially in patients with previous coagulopathy or in treatment with antithrombotic drugs for cardiovascular disease. The current practices of platelet/plasma transfusion in coagulopathic patients and of temporary suspension of the antithrombotic treatment before VAD insertion are based on local policies and are often inadequately supported by evidence, since many of the clinical studies on this topic are not recent and are not of high quality. Furthermore, the protocols of antithrombotic treatment have changed during the last decade, after the introduction of new oral anticoagulant drugs. Though some guidelines address some of these issues in relation with specific procedures (port insertion, etc.), no evidence-based document covering all the aspects of this clinical problem is currently available. Thus, the Italian Group of Venous Access Devices (GAVeCeLT) has decided to develop a consensus on the management of antithrombotic treatment and bleeding disorders in patients requiring VADs. After a systematic review of the available evidence, the panel of the consensus (which included vascular access specialists, surgeons, intensivists, anesthetists, cardiologists, vascular medicine experts, nephrologists, infective disease specialists, and thrombotic disease specialists) has structured the final recommendations as detailed answers to three sets of questions: (1) which is an appropriate classification of VAD-related procedures based on the specific bleeding risk? (2) Which is the appropriate management of the patient with bleeding disorders candidate to VAD insertion/removal? (3) Which is the appropriate management of the patient on antithrombotic treatment candidate to VAD insertion/removal? Only statements reaching a complete agreement were included in the final recommendations, and all recommendations were offered in a clear and synthetic list, so to be easily translated into clinical practice.
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Affiliation(s)
| | | | - Roberto Biffi
- Surgical Unit, Istituto Europeo di Oncologia, Milano, Italy
| | - Fabrizio Brescia
- Anesthesia and Intensive Care, Centro di Riferimento Oncologico, Aviano, Italy
| | - Igor Giarretta
- Internal Medicine, University Hospital "A.Gemelli," Rome, Italy
| | - Antonio La Greca
- Vascular Access Team, University Hospital "A.Gemelli," Rome, Italy
| | - Nicola Panocchia
- Nephrology and Dialysis Unit, University Hospital "A.Gemelli," Rome, Italy
| | | | | | - Fulvio Pinelli
- Anesthesia and Intensive Care, Careggi University Hospital, Firenze, Italy
| | - Mauro Pittiruti
- Vascular Access Team, University Hospital "A.Gemelli," Rome, Italy
| | - Domenico Prisco
- Experimental and Clinical Medicine, Careggi University Hospital, Firenze, Italy
| | - Tommaso Sanna
- Cardiology, University Hospital 'A.Gemelli', Rome, Italy
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Pittiruti M, Annetta MG, Marche B, D'Andrea V, Scoppettuolo G. Ten years of clinical experience with cyanoacrylate glue for venous access in a 1300-bed university hospital. Br J Nurs 2022; 31:S4-S13. [PMID: 35439068 DOI: 10.12968/bjon.2022.31.8.s4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In the past decade, cyanoacrylate glue has been progressively introduced into the clinical practice of venous access devices used for different purposes. Glue has been used to increase device stabilisation (to reduce the risk of catheter dislodgement), to seal the exit site (to both reduce local bleeding and decrease the risk of bacterial contamination) and to close skin incisions required for the insertion of tunnelled catheters or totally implanted venous ports. For many of these purposes, the efficacy and cost-effectiveness of cyanoacrylate glue has been demonstrated, while some indications are still controversial. This article reports on 10 years of clinical experience with cyanoacrylate glue in a large university hospital, and provides a narrative review of the scientific evidence on the benefits of glue in venous access that has been accumulating over the past decade.
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Affiliation(s)
- Mauro Pittiruti
- Vascular Access Specialist and Vascular Access Team Member, Department of Surgery, Fondazione Policlinico Universitario A Gemelli, Catholic University, Rome Italy
| | - Maria Giuseppina Annetta
- Vascular Access Specialist and Vascular Access Team Member, Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A Gemelli, Catholic University, Rome Italy
| | - Bruno Marche
- Vascular Access Specialist and Vascular Access Team Member, Department of Hematology, Fondazione Policlinico Universitario A Gemelli, Catholic University, Rome Italy
| | - Vito D'Andrea
- Neonatologist, Neonatal Intensive Care Unit, Fondazione Policlinico Universitario A Gemelli, Catholic University, Rome Italy
| | - Giancarlo Scoppettuolo
- Infectious Disease Specialist, and Consultant for the Vascular Access Team, Department of Infectious Disease, Fondazione Policlinico Universitario A Gemelli, Catholic University, Rome Italy
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Bertoglio S, Annetta MG, Brescia F, Emoli A, Fabiani F, Fino M, Merlicco D, Musaro A, Orlandi M, Parisella L, Pinelli F, Reina S, Selmi V, Solari N, Tricarico F, Pittiruti M. A multicenter retrospective study on 4480 implanted PICC-ports: A GAVeCeLT project. J Vasc Access 2022; 24:11297298211067683. [PMID: 35034480 DOI: 10.1177/11297298211067683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND PICC-ports may be defined as totally implantable central venous devices inserted in the upper limb using the current state-of-the-art techniques of PICC insertion (ultrasound-guided venipuncture of deep veins of the arm, micro-puncture kits, proper location of the tip preferably by intracavitary ECG), with placement of the reservoir at the middle third of the arm. A previous report on breast cancer patients demonstrated the safety and efficacy of these devices, with a very low failure rate. METHODS This retrospective multicenter cohort study-developed by GAVeCeLT (the Italian Group of Long-Term Venous Access Devices)-investigated the outcomes of PICC-ports in a large cohort of unselected patients. The study included 4480 adult patients who underwent PICC-port insertion in five Italian centers, during a period of 60 months. The primary outcome was device failure, defined as any serious adverse event (SAE) requiring removal. The secondary outcome was the incidence of temporary adverse events (TAE) not requiring removal. RESULTS The median follow-up was 15.5 months. Device failure occurred in 52 cases (1.2%), the main causes being local infection (n = 7; 0.16%) and CRBSI (n = 19; 0.42%). Symptomatic catheter-related thrombosis occurred in 93 cases (2.1%), but removal was required only in one case (0.02%). Early/immediate and late TAE occurred in 904 cases (20.2%) and in 176 cases (3.9%), respectively. CONCLUSIONS PICC-ports are safe venous access devices that should be considered as an alternative option to traditional arm-ports and chest-ports when planning chemotherapy or other long-term intermittent intravenous treatments.
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Affiliation(s)
- Sergio Bertoglio
- Department of Surgical Sciences, University of Genova, Genova, Italy
- General Surgery Unit 1, Ospedale Policlinico San Martino, Genova, Italy
| | - Maria Giuseppina Annetta
- Department of Anesthesia and Intensive Care, "A. Gemelli" University Hospital Foundation, Rome, Italy
| | - Fabrizio Brescia
- Anesthesiology and Intensive Care Unit, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Alessandro Emoli
- Department of Oncology, "A. Gemelli" University Hospital Foundation, Rome, Italy
| | - Fabio Fabiani
- Anesthesiology and Intensive Care Unit, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Maria Fino
- Vascular Access Center - General Surgery Unit, University Hospital, Foggia, Italy
| | - Domenico Merlicco
- Vascular Access Center - General Surgery Unit, University Hospital, Foggia, Italy
| | - Andrea Musaro
- Department of Oncologic Gynecology, "A. Gemelli" University Hospital Foundation, Rome, Italy
| | - Marina Orlandi
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Laura Parisella
- Anesthesiology and Intensive Care Unit, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Fulvio Pinelli
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Simona Reina
- General Surgery Unit 1, Ospedale Policlinico San Martino, Genova, Italy
| | - Valentina Selmi
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Nicola Solari
- General Surgery Unit 1, Ospedale Policlinico San Martino, Genova, Italy
| | | | - Mauro Pittiruti
- Department of Surgery, "A. Gemelli" University Hospital Foundation, Catholic University, Rome, Italy
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44
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Spencer TR, Pittiruti M, Miluy GO, Pacilli M. Letter Regarding: Open Versus Ultrasound Guided Tunneled Central Venous Access in Children: A Randomized Controlled Study. J Surg Res 2021; 267:712-714. [PMID: 34905819 DOI: 10.1016/j.jss.2021.04.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 11/28/2022]
Affiliation(s)
| | - Mauro Pittiruti
- Department of Surgery, Catholic University Hospital, Rome, Italy; World Congress of Vascular Access (WoCoVA) and Gli Accessi Venosi Centrali a Lungo Termine (GAVeCeLT)
| | | | - Maurizio Pacilli
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Department of Surgery, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.
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D'Arrigo S, Annetta MG, Iacobucci T, Dottarelli A, Pittiruti M. Should we consider preoperative PICC insertion for adult patients undergoing major surgery? J Vasc Access 2021; 24:520-521. [PMID: 34407660 DOI: 10.1177/11297298211040352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sonia D'Arrigo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Giuseppina Annetta
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Tiziana Iacobucci
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandra Dottarelli
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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46
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D'Arrigo S, Annetta MG, Musarò A, Distefano M, Pittiruti M. Secondary malposition of a PICC-port due to heavy physical exercise: A case report. J Vasc Access 2021; 24:507-510. [PMID: 34399639 DOI: 10.1177/11297298211039445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Physical exercise is often encouraged in cancer patients, mainly for the purpose of rehabilitation and for its psychological benefit. Some authors also suggest that exercise-specially in patient with peripherally inserted central venous access devices-may contribute to reduce the risk of catheter-related thrombosis. Still, the impact of physical exercise on the risk of device-related complications is not yet defined.We report a case of secondary migration of the tip of an arm port, caused by high-intensity exercise in a woman undergoing chemotherapy because of ovarian cancer. Tip migration was suspected because of malfunction (persistent withdrawal occlusion) and diagnosis established after ultrasound examination and chest x-ray.Even if exercise may yield benefit in the cancer patient on chemotherapy, the risk of mechanical complication of the venous access device-such as tip migration-should be considered in the case of high-intensity exercise.
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Affiliation(s)
- Sonia D'Arrigo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Giuseppina Annetta
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Musarò
- Oncologic Gynecology Unit, and Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mariagrazia Distefano
- Oncologic Gynecology Unit, and Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Brescia F, Pittiruti M, Ostroff M, Spencer TR, Dawson RB. The SIC protocol: A seven-step strategy to minimize complications potentially related to the insertion of centrally inserted central catheters. J Vasc Access 2021. [PMID: 34320856 DOI: 10.1177/11297298211036002.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2022] Open
Abstract
Insertion of central venous catheters in the cervico-thoracic area is potentially associated with the risk of immediate/early untoward events, some of them negligible (repeated punctures), some relevant (accidental arterial puncture), and some severe (pneumothorax). Furthermore, different strategies adopted during insertion may reduce or increase the incidence of late catheter-related complications (infection, venous thrombosis, dislodgment). This paper describes a standardized protocol (S.I.C.: Safe Insertion of Centrally Inserted Central Catheters) for the systematic application of seven basic beneficial strategies to be adopted during insertion of central venous catheters in the cervico-thoracic region, aiming to minimize immediate, early, or late insertion-related complications. These strategies include: preprocedural evaluation, appropriate aseptic technique, ultrasound guided insertion, intra-procedural assessment of the tip position, adequate protection of the exit site, proper securement of the catheter, and adequate coverage of the exit site.
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Affiliation(s)
- Fabrizio Brescia
- Unit of Anesthesia and Intensive Care Medicine, Vascular Access Team, Centro di Riferimento Oncologico di Aviano, IRCCS, Aviano, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | | | | | - Robert B Dawson
- Catholic Medical Center - Upper Connecticut Valley Hospital, Colebrook, NH, USA
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48
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Ostroff MD, Moureau N, Pittiruti M. Rapid Assessment of Vascular Exit Site and Tunneling Options (RAVESTO): A new decision tool in the management of the complex vascular access patients. J Vasc Access 2021. [PMID: 34289721 DOI: 10.1177/11297298211034306.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In the last decade, different standardized protocols have been developed for a systematic ultrasound venous assessment before central venous catheterization: RaCeVA (Rapid Central Vein Assessment), RaPeVA (Rapid Peripheral Vein Assessment), and RaFeVA (Rapid Femoral Vein Assessment). Such protocols were designed to locate the ideal puncture site to minimize insertion-related complications. Recently, subcutaneous tunneling of non-cuffed central venous access devices at bedside has also grown in acceptance. The main rationale for tunneling is to relocate the exit site based on patient factors and concerns for dislodgement. The tool we describe (RAVESTO-Rapid Assessment of Vascular Exit Site and Tunneling Options) defines the different options of subcutaneous tunneling and their indications in different clinical situations in patients with complex vascular access.
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Affiliation(s)
| | - Nancy Moureau
- PICC Excellence, Inc., Infinity Infusion Nursing, Griffith University, Hartwell, GA, USA
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Abstract
Short peripheral intravenous cannulas have different features, as they may be winged or non-winged, ported or non-ported, equipped or not with needle stick prevention and "blood stop" mechanisms, and integrated or not with preassembled extensions or preassembled needle free connector. In the current range of commercially available short peripheral cannulas, there is one device that is apparently associated with several clinical advantages. In fact, short peripheral cannulas with safety mechanisms, closed system, winged, non-ported, and equipped with preassembled extension and preassembled needle-free connector appear to be associated with prolonged dwell time, reduction of the incidence of several complications (infiltration/extravasation, dislodgement, phlebitis, infection, blood leakage), cost reduction, and increased satisfaction of patients and clinicians. To clarify the current terminology and to identify this device for future clinical studies, the authors advocate the use of the term "integrated short peripheral cannula." A rapid review of the current evidence suggests that this new device may have different clinical performance and different indications if compared to standard short peripheral cannulas. Though, the optimal clinical outcome can be achieved only when the device is inserted and maintained with proper protocols.
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Affiliation(s)
- Fulvio Pinelli
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Mauro Pittiruti
- Department of Surgery, Catholic University Hospital, Rome, Italy
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Zito Marinosci G, Biasucci DG, Barone G, D'Andrea V, Elisei D, Iacobone E, La Greca A, Pittiruti M. ECHOTIP-Ped: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in pediatric patients. J Vasc Access 2021. [PMID: 34256613 DOI: 10.1177/11297298211031391.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Central venous access devices are routinely used in pediatric care for administration of fluids and medications and for drawing blood samples. The adoption of ultrasound guided venipuncture, the availability of bedside ultrasound devices and the use of intraprocedural methods for tip location have been shown to reduce procedure-related complications, as documented by the recommendations of most recent guidelines. In pediatric patients, bedside ultrasound is a promising tool not only for optimizing the choice of the vein and guiding the venipuncture, but also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in pediatric patients, and to suggest a structured protocol for clinical practice.
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Affiliation(s)
- Geremia Zito Marinosci
- UOC di Rianimazione e Neuroanestesia, Azienda Ospedaliera di Rilievo Nazionale Santobono-Pausilipon, Neaples, Italy
| | - Daniele Guerino Biasucci
- Department of Emergency, Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Barone
- Neonatal Intensive Care Unit, Ospedale Infermi di Rimini, Azienda Unità Sanitaria Locale della Romagna, Rimini, Italy
| | - Vito D'Andrea
- Neonatal Intensive Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Daniele Elisei
- Department of Intensive Care and Anesthesia, Central Hospital, Macerata, Italy
| | - Emanuele Iacobone
- Department of Intensive Care and Anesthesia, Central Hospital, Macerata, Italy
| | - Antonio La Greca
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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